CHAUTAUQUA COUNTY
SCHOOL DISTRICTS’
MEDICAL HEALTH PLAN
*******
SUMMARY PLAN
DESCRIPTION
This municipal cooperative health benefit plan is not a licensed insurer. It operates under
a more limited certificate of authority granted by the superintendent of insurance.
Municipal corporations participating in the municipal health benefit plan are subject to
contingent assessment liability.
Adopted by the Chautauqua County School Districts’ Medical Health Plan Cooperative Members on February 16, 2001
Updated 10/1/02
SUMMARY OF BENEFITS
INDEMNITY MEDICAL PLAN SUMMARY
Annual Deductible
Depends on your District
Single
$50 or $100 or $200 per individual
Family
$100 or $200 or $400 per family
Annual Out of Pocket Maximum
$400 per individual or $300 per individual for participants in Option 4 of
the Prescription Drug Plan
Diagnostic X-ray and Laboratory
100% of Reasonable & Customary (R&C) – Please see definition on page 5 of Section I
Inpatient Hospital
100% of R&C for up to 365 days per confinement
Inpatient Mental Health; Chemical
Dependence or Abuse
100% of R&C for up to 30 days per year
Ambulance Services
100% of R&C coverage
Chiropractic Care
80% of R&C coverage after deductible
Outpatient Chemical Abuse and
Dependence Treatment
100% of R&C for up to 60 visits per year
Inpatient Physician
100% of R&C coverage
Outpatient Physician
80% of R&C after deductible
Surgery
Physician Charges
100% of R&C coverage
Facility Charges
100% of R&C coverage
Supplemental Accident
100% of R&C for the first $500 resulting from an accident
Annual OB/GYN
100% of R&C coverage for laboratory and test charges
Well Child Care
100% of R&C coverage
Therapy (Chemo, Phys., Radiation,
80% of R&C after deductible
Resp., Occ.)
PRESCRIPTION DRUG PLAN
Prescription through Medical Plan
80% of R&C after deductible
Prescription Drug card
Option 1
$1 copay
Option 2
$5 copay
Option 3
$5 copay for generics/$10 copay for brand drugs
Option 4
20% coinsurance per prescription up to the first
$100; then 100% coverage
DENTAL PLAN
Deductible
None
Maximums
$1,500 per year per person/ $1,000 lifetime orthodontia
Preventive/Diagnostic
90% of R&C coverage
Restorative/Endo/Periodontics
80% of R&C coverage
Prosthodontics
50% of R&C coverage
Orthodontia
50% of R&C coverage
VISION PLAN
100%
coverage
for exam, frames, and lenses after $15 copay.
In Network Option A
In Network Option B
Out-of-Network
Services limited to once per 24 months.
100% coverage for exam, frames, and lenses after $25 copay.
Services limited to once per 12 months.
100% coverage up to scheduled maximum for exam, frames and lenses.
Option A services limited to once per 12 months. Option B services limited to
once per 12 months
This is a brief summary of the benefits available. A complete description of your benefits, including any additional provision or
limitations is fully explained in the body of this document.
SUMMARY OF BENEFITS
POINT OF SERVICE MEDICAL PLAN SUMMARY – MANAGED CARE OPTION
IN-NETWORK BENEFIT –
HMO*
Annual Deductible
Single
Family
Coinsurance
Annual Out of Pocket Maximum
Diagnostic X-ray
Diagnostic Laboratory
Inpatient Hospital
Inpatient Mental Health; Chemical
Dependence or Abuse
Ambulance Services
Chiropractic Care
Outpatient Chemical Abuse and
Dependence Treatment
Inpatient Physician
Outpatient Physician
Surgery
Physician Charges
Facility Charges
Annual OB/GYN
Preventive Care
Adult Physical
Well Child Care – to age 19
Therapy (Chemo, Phys., Radiation,
Resp., Occ.)
Prescription Drug Card
Option 1
Option 2
None
None
N/A
N/A
$10 Copay
Covered in full – must utilize Quest labs.
Covered in full
Covered in full to a max. of 30
days
$50 Copay
$10 Copay
60 Visits @ $10 copay
Covered in full
$10 Copay
OUT-OF-NETWORK
BENEFIT**
$250
$500
20%
$2,000 Single/$4,000 Family
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
– maximum of 30 days covered
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
– 60-day max. benefit
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
Covered in full
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
$10 Copay
80% of Fee Schedule after deductible
$10 Copay
Covered in full
$10 Copay
80% of Fee Schedule after deductible
80% of Fee Schedule after deductible
No Coverage
PRESCRIPTION DRUG PLAN
Up to a 30 day Retail Supply
$7 Gernic/$15 Brandname
$5 Generic/$10 Preferred Brandname/$25 Other Brandname
* Member must select a Primary Care Physician (PCP) from the In-network Providers of the Medical
Administrator. To receive the greatest benefit under the Point of Service Plan, it is required that members
receive a referral from their PCP for all specialty care.
**Out-of-Network benefits are paid by the Plan if a member forgets to get a referral from their PCP and/or
receives care from a non-participating provider.
This is a brief summary of the benefits available. Not all districts offer all benefits. Please check with your district for your benefit eligibility. A complete
description of the benefits, including any additional provision or limitations is fully explained in Section VII of this Summary Plan Description.
Table of Contents
Section I & II – Introduction and Key Terms
Introductions ………………………………………………………………………………………
1
Key Terms………………………………………….…………………………………………...….
1
Section III – Medical Plan
Medical Plan .…………………………………………….…………………………………...……
1
Medical Plan Eligibility …………………………………………………………………….
1
…………………………………………………..……………………….……
1
Plan Contributions …………………………………………………..………………….…..
4
Summary of Medical Benefits……………………………………………..…………….….
4
Medical Plan Exclusions ………………..............................................................................
12
Summary of Prescription Drug Benefits …………………………………………............
14
Enrollment
Prescription Drug Exclusions ………………………………………………………...…… 16
Section IV – Dental Plan
Dental Plan ……….……………………………………………………………………………….
1
Dental Plan Eligibility ………………………………………………………………………
1
Dental Plan Coverage and Reimbursement Schedule ……………………………………
1
Dental Plan Deductibles ……………………………………………………………………
1
Pre-Authorization of Dental Benefits ……………………………………………………..
2
Dental Plan Exclusions ……………………………………………………………………..
2
Extension of Dental Benefits ………………………………………………………………..
2
Section V – Vision Plan
Vision Plan ………………………………………………………………………………………… 1
Vision Plan Eligibility …………………………………………………………………….....
1
Vision Plan Coverage ……………………………………………………………………….. 1
Vision Plan Exclusions and Limitations …………………………………………………… 2
Page i
Section VI – General Information
General Information ……………………………………………………………………………… 1
How to File a Claim ………………………………………………………………………… 1
Claim Appeal Procedures …………………………………………………………………..
4
When Coverage Ends ………………………………………………………………………. 15
Continuation of Coverage ………………………………………………………………….. 15
Coordination of Benefits …………………………………………………………………… 19
Administration ……………………………………………………………………………… 21
Statement of ERISA Rights ……………………………………………………………….. 25
Section VII – Point of Service Medical Plan
Summary of Medical Benefits …………………………………………………………………..
1
Description of Point of Service ……………………………………………………………
1
Out-of-Network Benefits ………………………………………………………………….
1
Covered Benefits …………………………………………………………………………..
2
Medical Plan Exclusions ………………………………………………………………….
10
Summary Of Prescription Drug Benefits ……………………………………………….
11
Prescription Drug Exclusions ……………………………………………………………
12
Key Terms …………………………………………………………………………………
12
Page ii
SECTION I
INTRODUCTION
&
SECTION II
KEY TERMS
I. INTRODUCTION
The Chautauqua County School Districts’ Medical Health Plan is an important component of the
benefits provided to school district employees. The Medical Health Plan supports you as you
address your own health care needs and those of your dependents. You may choose what medical
services you receive and who provides your health care – regardless of what the Plan covers or
reimburses. The Plan will reimburse for covered services as outlined in the remainder of this
booklet.
II. KEY TERMS
Following are certain words and phrases used in this document with the definition or explanation
of the manner in which the term is used for the purposes of this plan.
Actively at Work
An employee shall be considered actively at work if the employee reports for work on a specific
date at his/her usual place of employment for his/her participating employer, and such usual
place of employment is outside the employee's home or place of residence, and if when the
employee does so report, the employee is able to perform all of the usual and customary duties of
his/her occupation on a regular and full-time basis.
If an employee does not so report, or if his/her usual place of employment with his/her
participating employer is not outside the employee’s home or place of residence, he/she shall be
considered actively at work if at any time on the specific date he/she is neither a) hospitalconfined, nor b) disabled to any degree that he/she could not have then reported to a place of
employment outside of his/her home or residence, and c) could have performed all of the usual
and customary duties of his/her occupation on a regular full time basis.
Ambulatory Surgical Center
A lawfully operated facility that meets all of these tests:
- it is established, equipped and operated mainly to perform surgical procedures on an
outpatient basis;
- it is operated under the supervision of a staff of doctors and provides the full time services of
at least one registered graduate nurse;
- it is licensed by the jurisdiction in which it is located, or is approved by the Plan Sponsor;
- it has at least two operating rooms and at least one post-anesthesia recovery room;
- it maintains medical records for each patient;
- it has a written transfer agreement with one or more hospitals;
- it does not provide its own place for patients to stay overnight; and
- it is not an establishment which:
a) is operated by one or more doctors solely for their patients; or b) exists primarily for
purpose of terminating pregnancies.
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Birthing Center
A facility that is licensed by a state to provide prenatal, delivery, postpartum, newborn and
gynecologic services to pregnant women.
Coordination of Benefits
A cost-sharing mechanism through which benefits covered by more than one medical plan are
coordinated to allow maximum cost effectiveness and minimize multiple payments for a single
service.
Copayment
A percentage of the provider’s charge that you are responsible for after you meet your annual
deductible. For most services included in your Extended Medical coverage, your copayment is
20 percent.
Dependent
A covered person other than the covered member, including the following:
 Your legally married spouse
 Unmarried children under age 19 who are chiefly dependent on you for support and
maintenance
 Unmarried children age 19 or older until reaching 25 years of age, provided the child
is a full-time student in an educational institution or dependent on you for support and
maintenance*
 Unmarried children age 19 or older who are incapable of self-sustaining employment
by reason of mental illness, developmental disability, mental retardation, as defined in
the mental hygiene law, or physical handicap and who became so incapable prior to
the attainment of the age at which dependent coverage would otherwise terminate and
who are chiefly dependent upon such member for support and maintenance. The Plan
may ask you for proof of the handicap (if proof of the handicap is not produced
within 31 days of request, participation in the Medical Plan will end).
* Financial dependency is generally proved by being able to claim a dependent on your federal tax return or
by contributing more than 50% of the cost for your child’s support and maintenance.
Emergency Illness
In accordance with New York State law, an emergency condition is a medical or behavioral
condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent lay person, possessing an average knowledge of medicine
and health, could reasonably expect the absence of medical attention to result in placing the
health of the person afflicted with such condition in serious jeopardy; or in the case of a
behavioral condition placing the health of such person or others in serious jeopardy, or serious
impairment to such person’s bodily functions, or the serious dysfunction of any bodily organ or
part of such person, or the serious disfigurement of such person.
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Full-time Employee
An employee who customarily works a regularly scheduled work week, with a participating
employer, as determined by the individual district.
Home Health Agency
An organization, or its distinct part, that meets all these tests:
- its primary purpose is providing skilled nursing and other services on a visiting basis in the
covered person’s home;
- it is licensed or approved under any state or local standards that apply;
- it is run under policies established by a professional staff that includes doctors and registered
nurses;
- it is responsible for supervising the delivery of such services under a plan prescribed and
approved in writing by the attending physician; and
- it does not, except incidentally, provide care or treatment of mental illness, chemical
dependence or abuse, or care of a custodial nature.
Hospital
A place that meets all of these tests :
- its primary purpose is providing facilities supervised by one or more doctors to diagnose and
treat injury and illness;
- it provides day and night lodging which includes nursing service supervised by registered
graduate nurses;
- it complies with the laws pertaining to hospitals in its locality;
- it is accredited by the Joint Commission on Accreditation of Hospitals.
- It is not primarily a place for rest, or a place for the aged, nor is at a nursing home or a
convalescent home;
- As to mental illness, or the abuse of alcohol or drugs, the term "hospital " shall include
treatment centers; but any such center must be licensed or approved for such treatment under
the laws of its locality.
Hospital Confinement
A person shall be deemed to be confined to a hospital for the purposes of this plan, if room and
board charge is made in connection with his confinement; or if the confinement results from a
non-occupational injury requiring emergency care; or if the confinement is required because of a
surgical procedure. Successive periods of hospital confinements shall be considered a single
confinement unless:
- the Medical Plan Supervisor receives satisfactory evidence of complete recovery from the
first confinement, or
- in the case of an employee, the second confinement commenced after the employee had
returned to active service for at least 2 weeks
Incurred Expense
An expense will be considered to be incurred at the time the service or the supply to which it
relates is provided.
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Injury and Illness
In this plan the word "injury" means an accidental bodily harm. The word "illness" means:
- sickness that impairs a covered person's normal function of mind and body;
- the pregnancy, childbirth and related medical conditions of a covered person;
- a covered child's functional defect caused by premature birth or congenital malformation; and
- a covered child's "well baby care" as discussed below;
- complications of pregnancy, which includes: acute nephritis or nephrosis; cardiac
decompensation or missed abortion, or similar conditions as severe as these; a non-elective
caesarean section; an ectopic pregnancy; and spontaneous termination when a live birth is not
possible; and
- not included are: false labor; occasional spotting; doctor-prescribed rest; morning sickness;
pre-eclampsia; similar conditions not medically distinct from a difficult pregnancy.
Medically Necessary Coverage
Provided for any service or supply which is medically necessary, meaning that it is
professionally acceptable as essential to the treatment of the illness and is consistent with the
symptoms or diagnosis and treatment of the patient’s condition.
Medicare
The programs established by Title 18 or Public Law 80-70 (Statute 291) as amended, entitled
Health Insurance for the Aged Act, and which included Part A -Hospital Insurance Benefits for
the Aged; and Part B -Supplementary Insurance Benefits for the Aged.
Nurse
A Registered Graduate Nurse, or a Practical Nurse who is either licensed under the laws of the
state in which he or she resides or is registered by an organization operated with the approval of
the medical profession and not related by blood or marriage to the covered individual.
Nursery Charges
Expenses incurred by a newborn for routine care administered by a hospital or physician while
confined.
Physician
For the purposes of this document, a person who is a legally qualified physician or dentist,
podiatrist, psychologist, chiropractor, or osteopath to the extent only that they render services
within the scope of their licensed specialty to any person participating under this plan.
Plan Administrators
The entity assigned by the Plan Sponsors to administer the Plan. Such administrator shall have
the authority and responsibility of the establishment of the funding method, and shall establish
operating policy consistent with the objectives of the Plan, and except for establishing rates of
contribution, shall have the power to amend the Plan to meet the regulatory provisions of the Act
under which the Plan is created, or to protect the interests of the Plan participants.
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Plan Fiduciary
Any person, or organization, with respect to the plan who, or which (as the context may require)
exercises any discretionary authority or control respecting management or dispositions of any
Plan assets; or exercises any discretionary authority or responsibility of the administration of the
Plan. The named fiduciary, for this Plan, shall be the Plan Sponsor.
Plan Supervisor
Any person, or organization elected by the Plan or which (as the context may require), renders
any consulting service to the Plan Sponsors in connection with the operation of the Plan
including but not limited to, processing and payment of claims, and such other services
as may be delegated to it by the Plan Sponsor in accordance with the definitions of benefits
provided under this Plan. The Plan Supervisor's responsibility will be governed by the Plan
Document, and in no event shall the Plan Supervisor be vested with discretionary authority as to
the manner in which benefits are to be disbursed, or the manner in which any investment assets
of the Plan are managed. The Plan Administrator of this Plan shall be that person, or
organization, so identified in the Plan Document.
Reasonable and Customary (R&C)
The reasonable and customary charge is based on the prevailing charge for that service or
medical supply in the geographic area where it is provided. This “area” means a county or such
area as necessary to establish a representative cross section of persons or other entities regularly
furnishing the type of treatment, services or supplies for which the charge was made. Covered
plan expenses will be reimbursed at the 90th percentile of R&C data.
Semi-Private and Ward
When used in the context of defining the type of hospital accommodations used by a plan
participant, shall mean only those types of hospital room accommodations which are other than
one bed rooms, or accommodations.
Skilled Nursing Facility and Rehabilitation Center
A lawfully operated institution, or its distinct part, that meets all these tests:
- its primary purpose is providing lodging and skilled nursing care, day and night, for persons
recovering from an injury or illness;
- it is supervised on a full time basis by a doctor or registered nurse;
- it admits patients only upon the advice of a doctor;
- it keeps clinical records on all patients;
- it has the services of a doctor available at all times under an established agreement;
- it has established methods and procedures to dispense and administer
drugs and biologicals;
- it has a written transfer agreement with one or more hospitals;
- it is not, except incidentally, a place for rest, a place for the aged, a place for the treatment of
mental illness, chemical dependency or abuse.
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Surgical Procedure
- a cutting operation;
- suturing of a wound;
- treatment of a fracture;
- reduction of a dislocation;
- electrocauterization;
- diagnostic and therapeutic endoscopic procedures;
- injection treatment of hemorrhoids and varicose veins.
Totally Disabled
Disability to the extent that the employee is unable to perform substantially the usual and
customary duties of his occupation; with respect to the dependant coverages, (if provided under
the Plan) disability to the extent that the dependant is unable to perform the usual and customary
duties or activities of a person in good health and of the same age and sex.
Well Baby Care
Routine preventative health care that is not related to an accident or sickness but that consists of:
- the usual tests, exams and other services given to a child by a hospital within the first 7 days
of the child's life, and
- the usual periodic physical exams of a child by a doctor during the first year of the child's
life; this includes the immunizations, tests and laboratory services normally done with such
exams, as well as a routine circumcision.
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SECTION III
MEDICAL PLAN
III. MEDICAL PLAN
For Catastrophic Events…
The provisions of medical insurance helps to protect you from the financial hardship which high
medical expenses can cause.
…Along With Comprehensive Care
A basic medical plan combined with a major medical plan provides for a broad spectrum of
services ranging from coverage for physician office visits to prescription drug coverage to
inpatient hospitalization coverage.
This handbook outlines important provisions of the medical option available to the eligible
employees of the school districts that participate in the Chautauqua County School District’s
Medical Health Plan.
A. MEDICAL PLAN ELIGIBILITY
Employee Eligibility
All covered employees are eligible to participate in the medical plan subject to the terms and
conditions of your individual districts. At the time of enrollment, you may also elect to cover
your eligible dependents.
In addition to your biological children, any stepchildren, foster children, legally adopted
children, or children placed with you for adoption may also be covered if they meet the
above requirements.
Under a Qualified Medical Child Support Order (QMCSO), the requirements of proof of
dependency will be waived. If a medical child support order is received, the Plan
Administrator will determine whether the order is qualified and will notify you.
Retiree Eligibility
Retirees are eligible to continue coverage under the Plan, provided the individual school
districts permit retirees to continue coverage.
- If a retiree elects to continue coverage under the Plan, the retiree thereafter may
not receive any greater coverage than the coverage selected at the time of this election to
continue coverage.
- A retiree who elects to continue coverage subsequently may elect at any time to reduce
or cease their coverage under the Plan. An election to reduce or cease coverage will be
irrevocable and the coverage may never be restored, except:
- a retiree will be permitted to change their coverage status (single to family) if the
retiree’s dependent(s) experience a Qualifying Event and the retiree has been
continuously covered as a single contract under the Plan and the request to change
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coverage is made within 31 days of the event. A Qualifying Event will be considered an
event due to:
a. Loss of other group coverage because of loss of employment of the spouse
(laid off, terminated, reduction of hours or retirement).
b. Marriage
c. Death
d. Divorce
e. Loss of coverage due to a dependent child reaching the limiting age of other
group coverage that is lower than the Cooperative’s limiting age of 25.
- Retirees may never re-enroll in the Cooperative’s Plan if they previously declined
coverage at retirement or at a later date with the following exception:
a. If the retiree declines coverage at retirement because their spouse is a covered
active employee of a district covered by the Cooperative, they will be
permitted to re-enroll under their retiring district upon retirement of their
spouse, provided their district permits this change.
B. ENROLLMENT
Coverage for you and your dependents will become effective according to each district’s
requirements and upon submission of your enrollment form. Each eligible employee may
elect to obtain coverage for his or her eligible dependents by including the eligible
dependent’s information on the enrollment form, provided the application for coverage is
submitted within 31 days of the eligibility date. The effective date of coverage for an
employee’s eligible dependents will be the same date that the employee’s coverage becomes
effective. Once you are enrolled you will receive a medical plan identification card.
1. Coverage Levels
You may select from two levels of coverage:
 Employee-only
 Family (you plus any eligible family members)
2. If You Do Not Enroll Within 31 Days Of Eligibility
Coverage under the medical plan is not automatic. You must submit an enrollment form
within 31 days of first becoming eligible. Your individual school district will provide
you with materials to aid you in your enrollment decision.
If you fail to enroll within the 31 day period you will not be eligible for coverage until the
next July 1. So it is important that you return the completed enrollment form on time.
Prior to the July 1 effective date, during open enrollment (March 1 – March 31), you will
be given the opportunity to make benefit elections or changes.
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3. Open Enrollment And Mid-Year Coverage Changes
Open enrollment is conducted annually between March 1 and March 31 for coverage
starting July 1 and continuing for 12 months through the following June 30. Once a year,
you are given the opportunity to make coverage elections or changes. The new coverage
will take effect as of July 1st following the enrollment period. If you currently have
coverage and do nothing, you will retain the same coverage option that is in effect on
June 30.
If you are not currently covered, between March 1st and March 31st you may elect
coverage or if you are currently covered you may elect to change your coverage level
during that same period. For example, if you initially had elected single coverage,
despite being married, you may now elect dependent coverage.
Or on the other hand, if you had initially declined coverage entirely, you may enroll
during this period. If you do not change coverage during the open enrollment, a change
will not be allowed until the next open enrollment unless you experience a family status
change.
Once you complete your enrollment form and coverage for you and your dependents
begins, you may not revoke your election or make any changes in your coverage level
during that year unless you have a qualified change in family status (see below). If you
have a family status change, the Plan Administrator will determine if it is a qualified
change.
4. Adding Or Dropping Family Member Coverage
The following family status changes allow you to change coverage during a Plan year:
 Your marriage or divorce
 Death of your spouse or dependent
 Birth, adoption, or marriage of a dependent
 Termination or commencement of your spouse’s employment
 Change in your or your spouses employment status (from part-time to full-time or
vice-versa)
 Any unpaid leave of absence taken by you or your spouse
 You lose or gain significant health insurance coverage through your spouse’s
employer
New dependents acquired through “life events” (marriage, birth, adoption, foster care,
etc.) must be enrolled through a submission of an enrollment form within 31 days of the
event or wait until the next open enrollment to cover the dependent.
If the school district receives a court-ordered Qualified Medical Child Support Order
requiring that you provide health coverage for a child, your child may be enrolled even if
it is not within 31 days of a family status change.
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Any change in coverage as a result of a family status change as mentioned above must be
consistent with the change in family status.
5.
Special Enrollment Periods
If you are declining enrollment for yourself or your dependents because of other health
insurance coverage, you may in the future be able to enroll yourself or your dependents in
this plan. You must request enrollment within 31 days after your or your dependents’
coverage ends. If you have a new dependent as a result of marriage, birth, adoption or
placement for adoption, you may be able to enroll yourself and your dependents. You
must request enrollment within 31 days after the marriage, birth adoption or placement
for adoption.
C. PLAN CONTRIBUTIONS
Both you and the school district contribute toward the cost of your coverage. The amount of cost
sharing will depend on the plan and coverage level you select. You may obtain rate information
from your respective school district.
D. SUMMARY OF MEDICAL BENEFITS
Your medical plan benefits are separated into two separate categories; Basic Services and
Extended Medical Services. Prescription drug coverage is detailed in Section E.
1. Reasonable And Customary Charges Limits
The Plan does not cover amounts charged by providers in excess of the reasonable and
customary charge for any service or supply. The Claims Administrator regularly reviews
the reasonable and customary charge schedule. To confirm whether your provider's
charges are within the reasonable and customary limit, obtain a Predetermination of
Benefits. You can obtain a Predetermination of Benefits through a written request to the
Plan Administrator.
All descriptions of covered expenses mentioned throughout this Summary Plan
Description refer to the reasonable and customary charges
2. Basic Services Benefits – Key Features & Covered Benefits
a. INPATIENT HOSPITAL CARE
The following services are covered services under the Inpatient Hospital benefit:
 Bed, board and general nursing services in a semi-private room, up to 365 days per
confinement. A semi-private room is a room that the hospital considers to be semiprivate. If you occupy a private room in a participating hospital, the Plan will
cover up to the average charge for a semi-private room.
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









Bed, board and general nursing services in a private room, if such room is deemed
to be medically necessary
Use of operating, recovery and cystoscopic rooms and equipment.
Use of intensive care or special care units and equipment.
The administration and use of drugs, medications, sera, vaccines, intravenous
preparations to the extent these items are commercially available and readily
obtainable by the hospital.
Dressings and plaster casts.
Professional and equipment services in connection with the services listed below
under the condition that the services are provided by a hospital employee and the
charge for the services is payable to the hospital:
– Oxygen
– Physiotherapy
– Laboratory and pathological examinations
– Radiation therapy
– Chemotherapy
Use of equipment and supplies in connection with the services listed below.
Physician charges or professional fees charges for the following services are not
covered under the Basic Benefits portion of the medical plan, but can be
submitted to the Extended Medical portion for reimbursement:
– Anesthesia
– Electrocardiograms
– Electroencephalograms
– X-ray examinations
Blood products, except when participation in a volunteer blood replacement
program is available to you.
Any additional medical services and supplies which are customarily provided by
hospitals.
Bed, board, general nursing services, the use of equipment and supplies in
connection to a hospital stay for such period as is determined by the attending
physician in consultation with the patient to be medically appropriate after such
covered person has undergone a lymph node dissection or a lumpectomy for the
treatment of breast cancer or a mastectomy covered by the Plan. Coverage for the
length of stay in the hospital may not be restricted in a manner which is
inconsistent with the coverage provided to the portion of the stay that preceded
the lymph node dissection, lumpectomy or mastectomy.
b. EMERGENCY CARE
The Plan pays for 100% of covered charges for outpatient and emergency room
services with no deductible for services.
c. CARE IN CONNECTION WITH A SURGERY
The Plan pays for 100% of covered charges for facility and medical equipment
services with no deductible for outpatient surgical procedures.
Page 5
10/01/02
d. PRE-ADMISSION TESTING
The Plan will pay 100% of covered charges with no deductible for tests ordered by a
physician which are given to you before your admission to the hospital as a registered
bed patient for surgery provided the following conditions are met:
 They are necessary for and consistent with the diagnosis and treatment of the
condition for which surgery is to be performed;
 You have made a reservation for the hospital bed and for the operating room
before the tests are given;
 You are physically present at the hospital when the tests are given;
 Surgery actually takes place within 7 days after the tests were given.
e. HOME CARE
The Plan will pay 100% of covered charges for care received in your home by
certified Home Care agencies (as determined by New York State Public Health Law)
under the following conditions:
 If you did not receive Home Care visits, you would have to be hospitalized in a
hospital or cared for in a skilled nursing facility.
 A plan for your Home Care is established and approved in writing by a physician.
The following services are considered covered expenses under the Home Care
benefit:
 Part-time or intermittent home nursing care by or under the supervision of a
registered professional nurse (RN).
 Part-time or intermittent home health aide services which consist primarily of
caring for the patient.
 Physical, occupational or speech therapy if the Home Care Agency or hospital
provides these services.
 Medical supplies, drugs and medications prescribed by a doctor, but only if these
items are covered if you are confined in a hospital or skilled nursing facility.
 Laboratory services provided by or on behalf of the Home Care Agency or
hospital;
 Up to 365 visits in each calendar year. Each visit by a member of a Home Care
team is counted as one Home Care visit. Four hours of home health aide service
is counted as one Home Care visit.
f. AMBULANCE
Medically necessary transportation in an ambulance is covered at 100%.
Page 6
10/01/02
g. INPATIENT MENTAL HEALTH, CHEMICAL DEPENDENCE OR ABUSE
Coverage for inpatient care at an acute care facility will be covered at 100% for up to
30 days per year.
3. Extended Medical Benefits-Key Features
a. DEDUCTIBLE
Each calendar year, before the Extended Medical Portion of the Plan pays benefits,
you must satisfy a deductible. Depending on your school district, a medical plan
option with one of three deductible amounts will be offered:



$ 50 individual / $100 family
$100 individual / $200 family
$200 individual / $400 family
Most expenses under the extended medical portion of the Plan are subject to the
deductible, however, please review the specific coverage to determine if the
deductible applies.
The medical plan option you are offered by the school district may include a
prescription drug card plan. Your prescription drug copayment can be submitted to
the Medical Plan Supervisor for coverage under the extended medical benefit
(prescription drug plan coinsurance amounts can not be submitted to the medical plan
for reimbursement). If your medical plan does not include a prescription drug card,
you still have coverage for prescription drugs through the extended medical portion of
your plan (covered at 80% and subject to your annual deductible).
b. HOW THE FAMILY DEDUCTIBLE WORKS
The family deductible is designed to limit a family's annual outlay for covered
expenses before the Plan begins to pay benefits. Each family member's (including a
newborn's) covered expenses up to his or her per person deductible count toward the
family deductible. Once this family deductible is met, the Plan will begin to pay
benefits for all family members, including those who have not yet incurred expenses.
The Plan will also begin to pay applicable benefits for any covered family member
who meets the individual deductible, even if the total family deductible is not met.
The covered expenses incurred in October, November, and December of the prior
year that apply to that year’s deductible, will be applied to the current year’s
deductible.
Page 7
10/01/02
If two or more covered persons from the same family are injured in the same
accident, only one deductible will be applied each year against the expenses incurred
as a result of that accident.
c. 80% REIMBURSEMENT
After you have met your deductible (see below) the Plan reimburses 80% of the first
$2,000 of covered Extended Medical expenses. You pay the remaining 20% of
covered expenses - your coinsurance - until you have met your annual out-of-pocket
limit of $400 ($2,000 x 20%) after which the Plan will pay 100% of expenses for the
remainder of the calendar year.
d. OUT-OF-POCKET LIMIT
Except as provided below, this is a cap on the amount of unreimbursed covered
medical expenses you will have to pay in any one year. Once you reach your out-ofpocket limit, the Plan will pay 100% of your remaining covered expenses for that
year.
Most unreimbursed covered expenses for both you and your covered family members
count toward your out-of-pocket limit. Unreimbursed covered expenses include
deductible and coinsurance amounts but do not include amounts your physician or
health care provider may charge above the reasonable and customary charge (since
these amounts are not covered expenses) or amounts exceeding Plan limits. Mental
health and chemical abuse or dependence charges in excess of what the Plan
reimburses will not be applied toward meeting your Out-of-Pocket limit. Prescription
drug expenses reimbursed through prescription drug card plan at the 20% coinsurance
option (Option #4) do not apply towards your out-of-pocket limit.
In any calendar year, the Plan limits each participant’s out-of-pocket expenses
(excluding your deductible) to $400 ($300 for employees enrolled in the 20%
coinsurance [Option #4] under the prescription drug plan) per participant.
e. MEETING YOUR OUT-OF-POCKET LIMIT
As an example, to meet the individual out-of-pocket limit $400 if your individual
deductible is $100, you must incur a total of $2,100 in covered medical expenses. Of
this $2,100 you will pay $100 to meet your deductible and then 20% of each
remaining covered expense until the total amount you have paid equals $400. Thus, in
this example the total payment that you would be responsible for is equal to $500
($100 deductible + $400 out-of-pocket limit).
At that point, the Plan begins paying 100% of covered expenses rather than 80%, up
to any lifetime maximum or other Plan limitation.
Page 8
10/01/02
f. COMMONLY COVERED SERVICES
Includes, but may not be limited to the following (subject to deductible, coinsurance,
and out-of-pocket limit, unless otherwise noted):
(1) Allergy Treatment and Testing
The plan pays 100% with no deductible for allergy testing. Ongoing treatment of
allergies will be covered at 80%, subject to the annual deductible.
(2) Second Cancer Opinion
The plan pays 80% of covered charges, after the deductible is met, for a second
medical opinion by an appropriate specialist, including but not limited to a
specialist affiliated with a specialty care center for the treatment of cancer.
(3) Chiropractic Care
The plan pays 80% of covered charges, after the deductible is met, for
chiropractic care in connection with the detection or correction by manual or
mechanical means of structural imbalance, distortion or subluxation in the human
body for the purpose of removing nerve interference, and the effects thereof,
where such interference is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column.
(4) Diabetes
The plan pays 100% of covered charges, after the deductible is met, for the
following diabetes equipment and supplies when medically necessary: blood
glucose monitors and blood glucose monitors for the legally blind, data
management systems, test strips for glucose monitors and visual reading and urine
testing strips, insulin, injection aids, cartridges for the legally blind, syringes,
insulin pumps and appurtenances thereto, insulin infusion devices, and oral agents
for controlling blood sugar.
The plan pays 80% of covered charges, after the deductible is met, for diabetes
self-management education when medically necessary. Education provided by a
certified diabetes nurse educator, certified nutritionist, certified dietitian or
registered dietitian may be limited to group settings wherever practicable.
Coverage also includes home visits when medically necessary.
(5) Diagnostic X-ray and Laboratory Coverage
The plan pays 100% of coverage charges, without a deductible, for each
laboratory examination and x-ray examination performed in connection with the
diagnosis of an injury or illness.
(6) Hospital Expenses In Excess Of Basic Benefit Coverage
The Plan pays 80% of covered charges, after the deductible is met, in excess of
Basic Benefit coverage for medically necessary services, including outpatient
clinic and non-emergency services.
Page 9
10/01/02
(7) Outpatient Mental Health Treatment
The Plan pays 50% of covered expenses, after the deductible is met, for outpatient
mental health care.
(8) Outpatient Chemical Abuse or Dependence Treatment
The Plan pays 100% of covered charges for sixty outpatient visits for the
diagnosis and treatment of chemical dependence in any calendar year of which up
to twenty may be for family members. Such coverage is limited to facilities in
New York State which are certified by the office of alcoholism and substance
abuse services as outpatient clinics, as medically supervised ambulatory substance
abuse programs and, in other states, to those which are accredited by the joint
commission on accreditation of hospitals as alcoholism or chemical dependence
substance abuse treatment programs.
(9) Physician Fees
The Plan pays 100% of covered charges, not subject to deductible, for physicians
during an inpatient stay (up to one visit per physician per day). The Plan pays
80% of covered charges, after the deductible, for emergency room, outpatient
hospital, and office visit services provided by a physician, licensed physician’s
assistant or nurse practitioner.
(10) Physician Surgical Fees
The plan pays 100% of covered charges for surgical services provided by a
physician, second surgical opinions, and anesthesia services. These services are
not subject to the annual deductible. The Plan will cover assistant surgeon fees, at
100% with no deductible, up to a maximum of 25% of the primary surgeon’s
covered expenses.
(i) Breast Reconstruction After a Mastectomy
The plan pays 100% of covered charges for breast reconstruction after a
mastectomy including all stages of reconstruction of the breast on which the
mastectomy has been performed; and surgery and reconstruction of the other
breast to produce a symmetrical appearance.
(ii) Oral surgery
Surgical services for oral surgery are covered at 80% and are subject to the
annual deductible.
(11) Supplemental Accident Coverage
The Plan will cover at 100% for the first $500 for the covered charges resulting
from an accident. The charges must be incurred within 90 days of the accident to
be considered for coverage.
Page 10
10/01/02
(12) Routine Mammogram and Pap Smear
The plan will cover at 100%:
 an annual cervical cytology screening for cervical cancer and its precursor
states for women aged eighteen and older. The screening shall include an
annual pelvic examination, collection and preparation of a Pap smear, and
laboratory and diagnostic services provided in connection with examining and
evaluating the Pap smear;
 an annual mammogram for covered persons.
These benefits are available as an outpatient or in a physician’s office.
(13) Well-Child Care
The plan will cover at 100% the following services rendered to a covered
dependent from the date of birth through the attainment of nineteen years of age:
 an initial hospital check-up and well-child visits scheduled in accordance with
the prevailing clinical standards of a national association of pediatric
physicians;
 at each visit, a medical history, a complete physical examination,
developmental assessment, anticipatory guidance, appropriate immunizations
and laboratory tests;
 necessary immunizations for diphtheria, pertussis, tetanus, polio, measles,
rubella, mumps, haemophilus influenzae type b and hepatitis b.
Routine immunizations in connection with a well-child visit are covered at 100%
with no deductible.
(14) Other Medical Services
The Plan pays 80% of covered charges for the following health care services
when medically necessary:












Blood (including transfusion and the cost of whole blood and blood
components)
Cardiac rehabilitation
Chemotherapy
Dialysis
Durable medical equipment (except for diabetic and ostomy supplies which
are covered at 100%) – when accompanied by a letter of medical necessity
from the attending physician
Hospice
Physical therapy
Private duty nursing (up to four hours per day)
Radiation therapy
Respiratory therapy
Occupational therapy
Speech therapy
Page 11
10/01/02
4. Pregnancy And Maternity
Group health plans and health insurance issuers, under New York State law, must
provide maternity care coverage which, other than coverage for perinatal
complications, shall include inpatient hospital coverage for the mother and newborn
child for at least 48 hours after childbirth for any delivery other than a caesarian
section and for at least 96 hours following a caesarian section. Such coverage for
maternity care shall include the services of a midwife licensed pursuant to New York
State law and affiliated or practicing in conjunction with a facility licensed pursuant
to Article 28 of the Public Health law. In accordance with New York State law the
Plan is not required to pay for duplicative routine services actually provided by both a
licensed midwife and physician. The maternity care coverage shall include parent
education, assistance and training in breast or bottle feeding, and the performance of
any necessary maternal and newborn clinical assessments. The mother shall have the
option to be discharged earlier than the time periods stated earlier in this paragraph.
In such case, the inpatient hospital coverage includes one home care visit, which is in
addition to, rather than in lieu of, any other home care coverage available in the Plan.
The home care visit may be requested any time within 48 hours of the time of
delivery (96 hours for a caesarian section) and shall be delivered within 24 hours after
discharge or the mother’s request, whichever is later. Home care services covered
under the maternity benefit are not subject to deductibles, coinsurance or copayments. Coverage under the maternity benefit also includes the care and treatment
for, at a minimum, two prenatal visits and separate coverage for the delivery and
postnatal care.
5. Skilled Nursing Facility
Care provided through a skilled nursing facility will be covered at 80% subject to the
annual deductible for participating facilities and 80% of reasonable and customary
charges for a non-participating facility, subject to the annual deductible for up to 50
days per calendar year. Custodial care provided while in a skilled nursing facility is
not covered; the care must be in conjunction with healing, rehabilitative services to be
covered.
E. MEDICAL PLAN EXCLUSIONS
The following are not covered expenses under the Medical Plan:
 Travel expenses
 Volunteer Ambulance for which there is normally not a charge
 Non-inpatient related charges for cosmetic operations (except for reconstructive surgery
when it is incidental to or follows surgery resulting from trauma, infection or other
diseases of the involved body part or reconstructive surgery because of congenital disease
or anomaly of a covered dependent child which has resulted in a functional defect)
 Routine physicals and examinations including all laboratory and x-ray charges unless
otherwise stated
Page 12
10/01/02
E. MEDICAL PLAN EXCLUSIONS (continued)




























Services or care in connection with toenails (except full removal), corns, calluses; weak,
strained or flat feet; fallen arches; instability or imbalance of the foot
Marriage or vocational counseling
Television, telephone, or personal comfort items
Services rendered for bed rest, custodial care or convenience reasons
Special clothing, including orthopedic shoes
Personal hygiene items
Household equipment
Special food, diets, and food supplements (except for enteral formulas and modified solid
food products)
Equipment repairs and adjustments, unless due to a physical change
Routine eye examinations, eyeglasses and contact lenses, except following cataract
surgery or injuries sustained while covered by the Plan, in which case benefits will be
available for the contact lenses or regular lenses exclusive of frames
Hearing aids
Services covered under the Federal Employer’s Liability Act, Worker’s Compensation
Act or similar legislation, or under a No-Fault Insurance Policy
Services for which there is no cost to the member
Research or experimental procedures including services and equipment unless directed
pursuant to external review
Acupuncture
Hypnosis
Costs incurred while under an act-of-war
Injuries or illness arising from the commission of a crime
Any services or care for which coverage is available in whole or in part under the basic
contracts, or riders, if any
Services furnished to the covered person before the effective date of their coverage
Charges incurred for treatment on or to the teeth, the nerves or roots of the teeth, gingival
tissue, alveolar processes, treatment to the repair or the replacement of a denture or other
dental treatment; however, benefits will be payable for the surgical and the anesthesia
charges incurred for the removal of impacted teeth, or for such care or treatment due to
accidental injury to sound, natural teeth within 12 months of the accident or a congenital
disease or anomaly
Any deductibles or coinsurance under the Plan
Elective abortions
Services which are not medically necessary
Charges in excess of the reasonable and customary limits
Care or treatment for which payment is made by any local, state, or federal government
agency, including Medicare
Professional services performed by a member of the covered person’s immediate family
Massage Therapy except when deemed to be medically necessary by a physician and
performed in the office of a physician or chiropractor.
Page 13
10/01/02
F. SUMMARY OF PRESCRIPTION DRUG BENEFITS
1. Cost Sharing Options (Retail and Mail Order)
Prescription Drug coverage is provided through either the Extended Medical benefit or
through a Prescription Drug Card Plan. The prescription drug plan available to you
depends on the terms and conditions of your individual districts.
a. Extended Medical
Under the Extended Medical option, prescription drugs are covered at 80%, subject to
the annual deductible and out-of-pocket maximum as described in the Summary of
Medical Benefits Section. Your prescription drug plan ID card is the same as your
medical plan ID card.
b. Prescription Drug Card Plan
There are 4 options for the Prescription Drug Card Plan. The option available to you
depends on the terms and conditions of your individual districts. Each of the options
described below show the amount you pay for each prescription:



Option 1:
Option 2:
Option 3:

Option 4:
$1.00 copay per prescription (generic or brand name drugs);
$5.00 copay per prescription (generic or brand name drugs); or
$5.00 (generic drugs) / $10.00 (brand name drugs) copay per
prescription
20% coinsurance up to a maximum of $100 per
calendar year.
After you have paid $100 towards your
prescriptions in a calendar year, the plan will pay 100% of covered
charges.
Under the Prescription Card Plan, you will receive a separate Prescription Plan ID
card from the Prescription Plan Supervisor.
2. Participating and Non-Participating Pharmacies
If the prescription order for drugs covered under this program is filled, or if the insulin is
obtained, at a participating pharmacy, the covered individual will pay only the
copay/coinsurance applicable to the participant’s school district for each prescription
order or supply of insulin, upon presentation of the prescription drug ID card at the time
of purchase. A “participating pharmacy” is a pharmacy which is registered as a
pharmacy with the appropriate State licensing agency and which has an agreement with
the Plan to dispense drugs and insulin under the Prescription Drug Program.
Purchase of drugs at non-participating pharmacies requires that the participant pay that
pharmacy’s charge, obtain a receipt, and fill out a claim form. Reimbursement will be, as
determined by Prescription Plan Supervisor’s book-of-business data, at the lower of the
Page 14
10/01/02
average cost for the drug within the community in or near which it was filled, or the nonparticipating pharmacy’s actual charge, less the applicable co-pay.
If you are unsure whether a pharmacy is participating in the network, you can call the toll
free number on the back of your prescription drug identification card.
3. Limits on Dispensing Prescription Drugs
The quantity of drugs dispensed at a retail pharmacy under any one prescription order
under this program cannot exceed a supply sufficient to provide the prescription dosage
for up to thirty-five (35) consecutive days.
Some prescriptions may require prior authorization from the prescription drug
administrator before they are dispensed or may have quantity limits less than 35
consecutive days due to the nature of the drug and its efficacy.
Prescription orders for maintenance drugs may be dispensed in a supply sufficient to
provide the prescribed drug for up to 105 consecutive days. A “maintenance drug” is an
antiarthritic drug, anticoagulant drug, an anticonvulsant drug, a hormone, a thyroid
preparation, a cardiac drug or any other drug specifically designated as a chronic drug.
4. Mail Order Service
Another option is the mail order service, which allows participants to order up to a 105
day supply of a prescription medicine (where designated as “refill”) by mail. To use the
mail order service, send your prescription and a check, credit card number or money
order for your co-pay for the cost of the medication, in the mail order envelope.
5. Brand And Generic Drugs
Please note that unless your physician specifically prescribes a brand-name medicine, the
pharmacist will fill your prescription with a generic equivalent, in accordance with New
York State law.
6. Eternal Formulas And Modified Solid Food Products
The plan covers, subject to deductibles, coinsurance and co-payments as described above,
the cost of enteral formulas for home use for which a physician or other licensed health
care provider legally authorized to prescribe has issued a written order. Such written
order shall state that the enteral formula is clearly medically necessary and has been
proven effective as a disease-specific treatment regimen for those individuals who are or
will become malnourished or suffer from disorders, which if left untreated, cause chronic
disability, mental retardation or death. Specific diseases for which enteral formulas have
been proven effective shall include, but are not limited to, inherited diseases of aminoacid or organic acid metabolism; Crohn’s Disease; gastroesophageal reflux with failure to
thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction;
Page 15
10/01/02
and multiple, severe food allergies which if left untreated will cause malnourishment,
chronic physical disability, mental retardation or death. Coverage for certain inherited
diseases of amino acid and organic acid metabolism shall include modified solid food
products that are low protein, or which contain modified protein which are medically
necessary, and such coverage for such modified solid food products for any calendar year
or for any continuous period of twelve months for any covered individual shall not
exceed two thousand five hundred dollars.
G. PRESCRIPTION DRUG EXCLUSIONS
No coverage under the prescription drug benefit will be made for the following:









Drugs which do not require a written prescription, except insulin
Mechanical devices such as artificial appliances and therapeutic devices
Administration or injection of any drug
Vitamins, diet supplements, and similar items (except for prenatal vitamins, enteral
formulas and modified solid food products)
Drugs which are designated by Federal or New York State Law as experimental or
investigational unless directed pursuant to external appeal
Blood or plasma
Drugs dispensed to an enrollee while a hospital patient
Drugs dispensed to an enrollee while a patient at a nursing home or institution, if cost of
the drug is billed by the nursing home or institution
Drugs available under any Federal or State Law including any Worker’s Compensation
Act or similar law (except Medicaid)
Page 16
10/01/02
SECTION IV
DENTAL PLAN
IV. DENTAL PLAN
The Plan will pay a benefit for the reasonable and customary charges made by a dentist for
covered dental services provided to an eligible participant.
The amount of benefit will be determined according to the type of service provided and will not
exceed the applicable benefit percentage as shown for that service type in the schedule of
benefits
A. DENTAL PLAN ELIGIBILITY
All covered members are eligible to participate in the dental plan subject to the terms and
conditions of your individual districts. At the time of enrollment, you may also elect to cover
your eligible dependents.
B. DENTAL PLAN COVERAGE AND REIMBURSEMENT SCHEDULE
Type of Service
Diagnostic / Preventive Services
(Type A)
Reimbursement = 90%
Restorative Services / Endodontics /
Periodontia
(Type B)
Covered Dental Treatments
Oral exam, fluoride treatments,
x-rays
Fillings, extractions, root canal,
Periodontal treatment and oral
surgery (general anesthesia)
Reimbursement = 80%
Prosthodontics
(Type C)
Reimbursement = 50%
Orthodontia
(Type D) - Reimbursement = 50%
Inlays, onlays, crowns, dentures and
bridgework. Services for treatment
for TMJ, with a dental diagnosis,
including x-rays of teeth, study
models, crowns, restoration
(fillings), dentures, occlusal
adjustments, grinding down of teeth,
orthodontia, intra-oral appliances
(removable or fixed), adjustments to
intra-oral orthopedic appliances
Orthodontia for dependent children
under age 19 only
Limits/Exclusions
Twice per calendar year;
Full mouth series maximum, once
per 36 months
Treatment for appliances,
restorations, or services rendered for
the purpose of increasing vertical
dimension, restoring occlusion,
splinting, or replacing tooth structure
lost as a result of abrasion or attrition
Treatment for the replacement of any
prosthetic appliance, crown, gold
restoration or fixed bridge within 5
years of the date of the last
placement, unless required as a result
of injury
AND
for an initial placement of a denture
or fixed bridgework if involving
replacement of one or more teeth
extracted prior to the date of
coverage
Lifetime maximum - $1,000 per
individual
Calendar year maximum for all expenses: $1,500 per person.
C. DENTAL PLAN DEDUCTIBLES
There are no dental deductibles.
Page 1
10/0102
D. PRE-AUTHORIZATION OF DENTAL BENEFITS
This feature of the Plan lets you find out how much the Plan will pay before you begin
treatment with your dentist. It is intended to avoid any misunderstanding about coverage or
reimbursement and is not intended to interfere with your course of treatment. Before the
dentist starts a course of treatment, he will, at the participant’s request, prepare a treatment
plan – a written report detailing the dental procedures to be performed and the estimated
costs.
You should file the treatment plan (a regular dental claim form will suffice) with the Plan
Supervisor prior to the commencement of any work if the expected cost of treatment will
exceed $200. This enables the Plan to determine in advance its share of the cost of the
proposed treatment and also let you know how much of the cost you will be responsible for.
E. DENTAL PLAN EXCLUSIONS
The Dental Plan does not cover the following services or treatment:
 Performed before the employee or family member was covered by the Plan
 Furnished in a US Government hospital
 That would be free to you
 For orthodontic services, unless specifically provided under this plan
 For the replacement of lost or stolen appliances
 For appliances, restorations, or services rendered for the purpose of increasing vertical
dimension, restoring occlusion, splinting, or replacing tooth structure lost as a result of
abrasion or attrition
 For the replacement of any prosthetic appliance, crown, gold restoration or fixed bridge
within 5 years of the date of the last placement, unless required as a result of injury
 For an initial placement of a denture or fixed bridgework if involving replacement of one
or more teeth extracted prior to the date of coverage
 Fluoride treatment for members age 16 and over
 Sealants for member age 13 and over
 Orthodontia coverage for devices placed prior to the member’s effective date of coverage
under the Plan
 Services covered under the Federal Employer’s Liability Act, Worker’s Compensation
Act or similar legislation, or under a No-Fault Insurance Policy
F. EXTENSION OF DENTAL BENEFITS
The following benefits will not be covered if your dental coverage has terminated, unless the
treatment or service is rendered prior to the termination date of this coverage and the
treatment, including installation and fitting is completed within 60 days following
termination of this coverage:



Appliances or the modification of appliances
Crowns, bridges, or gold restoration
Root canal therapy
Page 2
10/0102
SECTION V
VISION PLAN
V. VISION PLAN
A. VISION PLAN ELIGIBILITY
All covered members are eligible to participate in the vision plan subject to the terms and
conditions of your individual districts. At the time of enrollment, you may also elect to cover
your eligible dependents.
B. VISION PLAN COVERAGE
The amount of benefit will be determined according to the type of service provided and will
not exceed the schedule of allowances as shown for that service type in the chart below.
Each school district participating in the Plan may elect to provide benefits either under
Option A or Option B. The difference between Option A and Option B is the copay required
for lenses and frames provided by a VSP doctor.
1. In Network Services
Plan A
Plan B
Coverage
Eye Examinations
Allowance
100%
Frequency
1 per 24 months
Allowance
100%
Frequency
1 per 12 months
Copay*
Eyeglass Lenses
Single
Vision
Bifocal
Trifocal
Lenticular
$15
N/A
$25
N/A
100%
100%
100%
100%
1 per 24 months
1 per 24 months
1 per 24 months
1 per 24 months
100%
100%
100%
100%
1 per 12 months
1 per 12 months
1 per 12 months
1 per 12 months
100% for
covered frame
1 per 24 months
100% for
1 per 24 months
covered frames
100%
1 per 24 months
100%
Frames
Contact Lenses**
Medically
Necessary
Elective
100% up to
$105
1 per 24 months
100% up to
$105
* For services provided by a VSP Doctor; the copay covers both lenses and frames.
** Medically necessary contact lenses must be prescribed by a VSP doctor for certain
conditions. Your VSP doctor must get prior approval from VSP for medically necessary
contact lenses.
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A directory of participating VSP doctors is available from your benefits representative or
from VSP’s internet site www.vsp.com.
2. Out of Network Services
If you choose to visit a non-VSP doctor, the plan will cover the same services at the same
frequency, subject to the following limits:
Eye Examinations:
Single Vision Lenses
Bifocal Lenses
Trifocal Lenses
Lenticular Lenses
Frames
Medically Necessary
Contact Lenses
Elective Contacts
100% coverage up to $35
100% coverage up to $25
100% coverage up to $40
100% coverage up to $55
100% coverage up to $80
100% coverage up to $35
100% coverage up to $210
100% coverage up to $105
C. VISION PLAN EXCLUSIONS AND LIMITATIONS
The vision plan is designed to cover your visual needs rather than cosmetic materials.
However, the Vision Plan Supervisor may have negotiated reduced fees for the following
services:











Blended lenses
Contact lenses (except as described above)
Oversize lenses
Progressive multifocal lenses
Photochromic or tinted lenses other than Pink #1 or #2
Coated or laminated lenses
A frame that costs more than plan allowances
Certain limitations on low vision care
Cosmetic lenses
Optional cosmetic procedures
UV protected lenses
The following services are not covered:
 Orthoptics or vision training and associated supplemental testing;
 Plano lenses (non-prescription);
 Two pair of glasses in lieu of bifocals;
 Lenses and frames furnished under this Plan which are lost or broken will not be replaced
except at normal intervals when services are otherwise available;
 Medical or surgical treatment of the eyes;
 Any eye examination, or corrective eye wear, required by an employer as a condition of
employment.
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SECTION VI
GENERAL INFORMATION
VI. GENERAL INFORMATION
A. HOW TO FILE A CLAIM
1. Medical
How you file a claim depends on both your employment status and your Medicare
eligibility. The claim filing procedure is the same regardless if the coverage is under the
Basic or Extended Medical option.
a. IF YOU ARE AN ACTIVE PARTICIPANT OR A RETIREE NOT ELIGIBLE FOR
MEDICARE
Claims for all medical services should be sent to the Medical Plan Supervisor. If you
receive services from a hospital within New York State, present your Medical Plan
Identification Card during the admission procedures. This will allow the hospital to
forward the bill to the Medical Plan Supervisor for payment as well as receive
payment from the Medical Plan Supervisor directly.
For services received from a non-participating hospital, the hospital will send you the
bill. You should forward the itemized bill to the Medical Plan Supervisor at the
address listed on page 25 of Section V General Information.
Be sure to include your subscriber and group number on the bill. Both these numbers
are found on your medical plan Identification Card. All claims must be submitted for
consideration within 15 months of the date on which services were provided. Claims
older than 15 months will be denied.
b. IF YOU ARE A RETIREE WHO IS ELIGIBLE FOR MEDICARE
All claims should be submitted to Medicare FIRST. Present your Medicare card at
the time you receive services. For hospital services, also present your Medical Plan
Identification Card; this will allow the hospital to bill the Medical Plan Supervisor
directly after it receives payment from Medicare. Should the hospital bill you directly
instead of sending the bill to the Medical Plan Supervisor, submit both the itemized
hospital bill and the Medicare explanation of benefits (EOB) to the Medical Plan
Supervisor for payment consideration.
Once you receive the Medicare EOB, submit both the itemized bill and the Medicare
EOB as outlined in the “If you are an active participant OR a retiree not eligible for
Medicare” section above.
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(1) When Medicare is the Secondary Payer
Medicare will pay in a secondary position in the following circumstances:
 The services are reimbursable under automobile medical, no fault or any
liability insurance;
 The Medicare beneficiary is 65 or older and has employer group health plan
coverage through his or her own employment or the employment of a spouse
(of any age);
 The Medicare beneficiary is entitled to Medicare solely on the basis of end
stage renal disease (ESRD); in this instance Medicare is secondary to an
employer group health plan for a period of up to 12 months after the
individual has been determined to be eligible for ESRD benefits; and
 The Medicare beneficiary is disabled (except in the case of ESRD) and elects
to be covered by an employer group health plan as a current employee of an
employer with 100 or more employees or the family member of such
employee.
2. Dental
The Plan will initially provide you with claim forms and your own Dental Plan
Identification Card. Subsequent claim forms may be obtained from your employer. The
claim forms contain instructions as to how they should be completed and where they
should be sent. Be sure to fully complete your portion of the form. Unanswered
questions may delay the processing of your claim. Once you have completed your
portion of the claim form, submit to your dentist so his/her portion may be completed and
forwarded to Dental Plan Supervisor for payment.
3. Vision
a. PARTICIPATING PROVIDERS
When you make the appointment with a VSP doctor, notify the doctor that you are a
VSP member. The doctor will ask you for some general information such as your
name and date of birth, the group providing VSP coverage (Chautauqua County
School Districts’ Medical Health Plan) and your social security number. Once the
doctor verifies your eligibility, any portion of your covered expenses not reimbursed
by the Plan will be due at the end of your appointment with your VSP doctor.
b. NON-PARTICIPATING PROVIDERS
Eligible participants can receive covered services or materials from a nonparticipating provider. In this case, the participant must pay the non-participating
provider and submit an itemized bill along with their benefit form to the Plan for
reimbursement.
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The participant will be reimbursed by the Plan in accordance with the Plan’s schedule
of allowances for non-participating providers. All vision claims must be submitted to
the Plan within one year of when the services were completed.
Remember to include the following information when submitting a bill from a nonVSP doctor:
 The doctor’s bill, including a detailed list of the services you received
 The covered member’s VSP member identification number (usually the Social
Security Number)
 The covered member’s name, phone number, and address
 The Plan name (Chautauqua County School Districts’ Medical Health Plan)
 Your name, date of birth, phone number and address
 Your relationship to the covered member (spouse, self, child, etc.)
Send the original bill and required information (keep a copy for your records) to:
Vision Service Plan
Attn: Non-Member Doctor Claims
P.O. Box 997105
Sacramento, CA 95899-7105
4. Prescription Drug
a. RETAIL PROGRAM (Participating and Non Participating Pharmacies)
You will receive member ID cards and a listing of the Participating Pharmacies in
Chautauqua County. You must present your ID card to your pharmacist each time you
receive a prescription medication. You can also call the toll free number on your ID
card to locate participating pharmacies anywhere in the country.
If you visit a participating pharmacy, there is no claim filing; you simply pay the
pharmacy your copayment/coinsurance.
For non-participating pharmacies, you will need to pay the pharmacy in full for your
prescription and send the claim to the Prescription Drug Supervisor for
reimbursement. Be sure to include the original prescription receipt that shows the
date, who the prescription is for, the drug prescribed and the quantity prescribed.
b. MAIL SERVICE PROGRAM (Participating pharmacies only)
For any of the available copayment plans, to use the mail service, complete the mail
service patient profile for each covered family member, and mail it along with your
original prescription and applicable copayment. (You will need to contact your
physician to obtain a new prescription for any medications you currently take. Have
your physician write the prescription for a three month (105 day) supply, with up to
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three refills. In many cases, your physician will be able to arrange for a new
prescription without requiring an office visit.)
For the prescription card plan 20% coinsurance option, you may call the Prescription
Plan Supervisor to determine your applicable cost for mail order prescriptions. You
may also be able to charge your prescriptions to a credit card through the mail order
program. (You will need to contact your physician to obtain a new prescription for
any medications you currently take. Have your physician write the prescription for a
three month (105 day) supply, with up to three refills. In many cases, your physician
will be able to arrange for a new prescription without requiring an office visit.)
For new prescriptions, once you have submitted a member profile, you can either
mail the original prescription, or have your physician fax it directly to the mail
service facility.
c. PRESCRIPTIONS COVERED UNDER EXTENDED MEDICAL
If you do not have a prescription card plan available and your prescription coverage is
provided through the Extended Medical option, you can submit your prescription
claims the same way you submit any other medical expense through the Extended
Medical option.
d. PRESCRIPTION CARD PLAN COPAYS
Any copays you are responsible for under the prescription card program (Rx Card
Options 1-3) can be submitted for coverage under the Extended Medical option. If
you have the 20% coinsurance option (Option 4) under the prescription card plan, you
may not submit your coinsurance amounts to the Extended Medical option for
reimbursement.
B. CLAIM APPEAL PROCEDURES
If a claim is denied in whole or in part, the covered person will receive notification delivered
in the same manner as reimbursement for a claim.
The insurance carrier will provide an explanation of benefits (EOB). The EOB will show the
calculation of the total amount payable, any charges not payable and the reason for charges
not payable. If additional information is needed for consideration of a claim, the insurance
carrier will request it.
If an exception is taken to a denied claim and it cannot be resolved to the individual’s
satisfaction, the individual will be referred to the local school advisory committee. A claim
review may be obtained by filing a written request with the local school advisory committee,
which will then file the claim review with the Plan Administrator.
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On receipt of a written request for review of a claim, the Plan Administrator will review the
claim and be furnished with copies of all pertinent documents (except any information in the
participant’s claim history which the participant or physician does not wish to be made
known). Please contact your district’s business office to determine where you may submit
opinions of what the issues are and any comments.
1. Utilization Review Procedure
This section explains our utilization review procedure. Utilization review (UR) decisions
relate to the medical necessity of care, including the appropriateness of the level of care
or the provider of care; or to the experimental and/or investigational nature of care. UR
decisions are made when prior authorization is requested for care (the “prospective
review process”), during the course of care (the “concurrent review process”), and after
care is rendered (the “retrospective review process”).
Examples of cases that would be reviewed under the UR procedure include our refusal of
prior authorization for an inpatient hospital stay because the care is available on an
outpatient basis; or our determination that you can be released from a hospital because
your condition no longer requires you to have 24-hour nursing service; or our
determination that the treatment you received is experimental and/or investigational, in
light of your condition.
The steps of the UR procedure are as follows:
a. PRIOR AUTHORIZATION PROCESS
All requests for prior authorization of care are reviewed to determine medical
necessity (including the appropriateness of the proposed level of care and/or provider)
and to determine whether the care is experimental and/or investigational. The initial
review is performed by a nurse. If the nurse determines that the proposed care is
medically necessary and not experimental and/or investigational, the nurse will
authorize the care. If the nurse determines that the proposed care is not medically
necessary or is experimental and/or investigational, or that further evaluation is
needed, the nurse will refer the case to a clinical peer reviewer (a physician who
possesses a current and valid nonrestricted license to practice medicine, or a health
care professional other than a licensed physician who, where applicable, possesses a
current and valid nonrestricted license, certification, or registration or, where no
provision for a license, certificate, or registration exists, is credentialed by the
national accrediting body appropriate to the profession and is in the same
profession/specialty as the health care provider who typically manages the medical
condition). Failure to make a determination within the time periods required by
Article 49 of the New York Insurance Law will be deemed to be an adverse
determination that is subject to Level one Internal appeal (described in “Review of
Adverse Determinations”, below).
Notice of an approval of proposed care or an adverse determination that proposed
care is not medically necessary or is experimental and/or investigational will be
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provided to you or your authorized designee, and your provider, by telephone and in
writing, within 3 business days following receipt of all information necessary to make
the decision.
The notice of any adverse determination will include the reasons, including clinical
rationale, for our determination. The notice will also advise you of your right to a
review of the adverse determination, give instructions for initiating standard
expedited and external appeals, and specify that you may request a copy of the
clinical review criteria used to make the adverse determination. The notice will also
specify additional information or documentation, if any, needed for us to make a level
One internal appeal determination.
If, prior to making an adverse determination, no attempt was made to consult with the
provider who requested the prior authorization, the provider may request
reconsideration by the same clinical peer reviewer who made the adverse
determination. The reconsideration will take place within 1 business day of the
request of reconsideration, in consultation with the requesting provider. If the
adverse determination is upheld, notice will be given to the provider, by telephone
and in writing, within 3 business days from the date of reconsideration. All of the
information described in the paragraph above will be included in this notice.
b. CONCURRENT REVIEW PROCESS
When you are receiving services that are subject to concurrent review, a nurse will
periodically assess the medical necessity and experimental and/or investigational
nature of services you receive throughout the course of treatment.
Once a case is assigned for concurrent review, a nurse will determine whether the
services being received are medically necessary and not experimental and/or
investigational. If so, the nurse will authorize care. If the nurse determines that the
care is not medically necessary or is experimental and/or investigational; or that
further evaluation is needed; the nurse will refer the case to a clinical peer reviewer
(defined in “Prior Authorization Process” above). Failure to make a determination
within the time periods required by Article 49 of the New York Insurance law will be
deemed to be an adverse determination that is subject to Level One internal appeal
(described in “Review of Adverse Determinations” below).
Your provider will be notified of the concurrent review decision, by telephone and in
writing, within 1 business day following our receipt of all information or
documentation needed for the review.
If care is authorized, the notice will identify the number of approved services, the new
total of approved services, the date services may begin, and the date of the next
scheduled concurrent review of the case. If care is not authorized, the notice of any
adverse determination will include the reasons, including clinical rationale, for our
determination. The notice will advise you of your right to a review of the adverse
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determination, give instructions for initiating standard expedited and external appeals,
and specify that you may request a copy of the clinical review criteria used to make
the adverse determination. The notice will also specify additional information or
documentation needed, if any, for us to make a Level One Internal appeal
determination.
If, prior to making an adverse determination, no attempt was made to consult with the
provider who requested the prior authorization, the provider may request
reconsideration by the same clinical peer reviewer who made the adverse
determination. The reconsideration will take place within 1 business day of the
request for reconsideration, in consultation with the requesting provider. If the
adverse determination is upheld, notice will be given to the provider, by telephone
and in writing, within 1 business day from the date of reconsideration. All of the
information described in the paragraph above will be included in this notice.
c. RETROSPECTIVE REVIEW PROCESS
At our option, a nurse will review retrospectively the medical necessity and the
experimental and/or investigational nature of services, which are subject to utilization
review. If the nurse determines that care you received was medically necessary and
not experimental and/or investigational, the nurse will authorize benefits. If the nurse
determines that the care was not medically necessary or was experimental and/or
investigational, the nurse will refer the case to a clinical peer reviewer (defined in
“Prior Authorization Process” above). Failure to make a determination within the
time periods required by Article 49 of the New York Insurance Law will be deemed
to be an adverse determination that is subject to Level One Internal appeal (described
in “Review of Adverse Determinations” below).
You or your authorized designee and your provider will be notified of the
retrospective review determination, in writing, within 30 calendar days from our
receipt of all information or documentation needed for the review.
The notice of any adverse determination will include the reasons, including clinical
rationale, for our determination. The notice will advise you of your right to request a
review of the adverse determination, give instructions for initiating standard
expedited or external appeals, and specify that you or your authorized designee may
request a copy of the clinical review criteria used by us to make the adverse
determination. The notice will also specify additional information or documentation
needed, if any, for us to make a Level One internal appeal determination.
The provider who rendered care for which benefits are denied may request a Level
One internal appeal of the retrospective adverse determination on your behalf (even if
not authorized in writing by you to act as your designee).
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d. REVIEW OF ADVERSE DETERMINATIONS
(1) Request for Level One Internal Appeal
You, your authorized designee, and, in a retrospective review case, your health
care provider may request a Level One internal appeal of an adverse
determination, verbally or in writing, within 60 business days from the date that
you receive notice of the adverse determination. (If the notice you received did
not specify all information required to conduct a Level One internal appeal, the
time period for you to request the review will be extended.) To request a Level
One internal appeal verbally, you may call the plan administrator, or visit us in
person. To submit a written request for Level One internal appeal, you may write
to the plan administrator.
The procedure that we will follow in reviewing your case will differ, depending
upon the urgency of the case. In most cases, a standard Level One internal
appeal, described below, will be appropriate. In “urgent cases,” an expedited
Level One appeal is available; expedited Level One internal appeal is described
after standard Level One internal appeal below.
(2) Standard Level One Internal Appeal
We will acknowledge your Level One internal appeal in writing, within 5
business days after receiving it. The acknowledgment will advise you of the
department (including the address and telephone number) designated to respond
to the appeal.
When one or more Level One internal appeals are received (for example, you
submit an appeal, then your health care provider submits an appeal on your
behalf), a single Level One internal appeal will be conducted by a clinical peer
reviewer (a physician who possesses a current and valid nonrestricted license to
practice medicine, or a health care professional other than a licensed physician
who, where applicable, possesses a current and valid nonrestricted license,
certification, or registration or, where no provision for a license, certificate, or
registration exists, is credentialed by the national accrediting body appropriate to
the profession and is in the same profession/specialty as the health care provider
who typically manages the medical condition), who did not make the initial
adverse determination.
The clinical peer reviewer will render a determination within 30 calendar days
after receipt of all necessary information. Written notice of the determination will
be provided to you and any other qualified party who submitted a Level One
internal appeal within 2 business days after the determination is made, but in no
event later than 30 calendar days after receiving all necessary information.
Failure to render a determination within the time periods required by Article 49 of
the New York Insurance Law will be deemed to be a reversal of the initial adverse
determination.
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The notice will include detailed reasons and the clinical rationale for the
determination. If the determination is adverse, the notice will describe the
procedure for filing a Level One internal appeal. It will also describe the process,
and enclose an application, for requesting an external appeal of the adverse
determination. The external appeal process is described in below. If you submit a
Level Two internal appeal, the appeal may take longer than the 45-day time frame
for requesting an external appeal through New York State, which begins on the
date you receive the final adverse determination notice upon completion of Level
One internal appeal.
(3) Expedited Level One Appeal
For cases involving a prospective or concurrent (but not retrospective) review
decision (such as the review of continued or extended health care services;
additional services rendered in the course of continued treatment; or any other
issue with respect to which a provider requests an immediate review), you, your
authorized designee, or a provider may request an expedited Level One internal
appeal of the initial adverse determination.
When a request for expedited Level One internal appeal is received, the appeal
will be conducted by a clinical peer reviewer (defined in “Standard Level One
Internal Appeal” above) who did not render the initial adverse determination. The
Customer Service Department will provide reasonable access to the clinical peer
reviewer assigned to the appeal, within 1 business day following receipt of notice
of the request for appeal, to ensure that all relevant information in available to the
clinical peer reviewer. You may ask that your provider and the clinical peer
reviewer exchange information by telephone or fax.
Within 48 hours of receipt by us of all information needed for the appeal, the
clinical reviewer will render a determination on the expedited Level One internal
appeal. Failure to render a determination within the time periods required by
Article 49 of the New York Insurance Law will be deemed to be a reversal of the
initial adverse determination.
Notice will be provided to you and the provider, by telephone and in writing,
within 24 hours of the determination. The notice will include all of the
information described and enclosed in a notice of standard Level One internal
appeal determination (see “Standard Level One Internal Appeal” above). Note –
If you request a Level Two internal appeal, the appeal may take longer than the
45-day time frame for requesting an external appeal through New York State,
which begins on the date you receive the final adverse determination notice upon
completion of Level One internal appeal.
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(4) Level Two Internal Appeal
After you receive notice of a Level One internal appeal determination, if you are
still not satisfied, you or your authorized designee may submit a Level Two
internal appeal, verbally or in writing. (You also have an option to apply for an
external appeal; see “External Appeal” below). The Level Two internal appeal
must be received by us within 60 business days from the date of the Level One
internal appeal determination.
We will acknowledge your Level Two internal appeal, in writing, within 15
calendar days after receiving it. The acknowledgement will advise you of the
department (including the address and telephone number) designated to respond
to the appeal, and will identify additional information, if any, needed for the Level
Two appeal.
You case will be reviewed by at least one clinical peer reviewer (defined in
“Standard Level One Internal Appeal” above) who did not make the prior
determinations.
In “urgent cases,” where a delay would significantly increase the risk to your
health, we will make a Level Two internal appeal determination and call you
within the lesser of 2 business days or 72 hours after receiving all information
needed for the review. Written notice of the Level Two internal appeal
determination will also be provided within 2 business days.
The notice you receive will include detailed reasons for the Level Two internal
appeal determination and, if a clinical matter is involved, the clinical rationale for
the determination. The notice will also advise you of the right to apply for an
external appeal, if the time frame for applying has not expired by the date of
receipt of notice of an adverse determination on Level Two internal appeal.
(5) External Appeal
In general
You have the right to an “external appeal” of certain coverage determinations
made by us or on our behalf. An external appeal is an independent review of a
coverage determination by a third party known as an External Appeal Agent.
External Appeal Agents are certified by New York State; and may not have a
prohibited affiliation with any health insurer, health maintenance organization
(HMO), medical facility, or health care provider associated with the appeal. In
this section, “requested service” or “requested services” refers to the service or
services for which you are requesting coverage.
You may have the right to an expedited external appeal if your attending
physician attests that a delay in providing the requested service would pose an
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imminent or serious threat to your health. The time frames for expedited external
appeals are shorter than the time frames for standard external appeals.
You may request an external appeal only if the requested service is covered under
the contract.
(i) Coverage Determinations Subject To External Appeal
This subparagraph describes the general conditions for external appeal.
In general, you may not request an external appeal unless we have issued a
“final adverse determination” with respect to your request for coverage after
our Level One internal appeal. You may ask us to agree to an external appeal
even though you have not obtained a final adverse determination after Level
One internal appeal; however, we have no obligation to agree to your request.
If we do agree, we will send you a letter stating that we have agreed to an
external appeal even though you have not obtained a final adverse
determination.
To be eligible for external appeal, the final adverse determination issued upon
completion of our Level One internal appeal must be based on a determination
that the requested service is not medically necessary, or that the requested
service is experimental and/or investigational. You do not have the right to an
external appeal of any other determinations, even if those other determinations
affect your coverage.
(ii) Conditions For External Appeal Of Determinations Of Medical Necessity
You may request an external appeal of a final adverse determination of
medical necessity that is issued upon completion of Level One internal appeal,
if you meet the conditions of this subparagraph and the general requirements
of subparagraph (i). above. The provisions of this subparagraph apply only to
external appeal of medical necessity determinations.
To request external appeal under this subparagraph, the final adverse
determination must indicate that the requested service is or was not medically
necessary.
(iii)Conditions For External Appeal Of Determinations Involving Experimental
And/Or Investigational Treatment
This subparagraph governs the external appeal of determinations involving
experimental and/or investigational treatment. This subparagraph does not
govern determinations involving services provided in clinical trials, which are
governed by the section below.
To request an external appeal under this subparagraph, your attending
physician must certify that you have a life-threatening or disabling condition
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or disease. A “life-threatening condition or disease” is one that, according to
the current diagnosis of your attending physician, has a high probability of
causing your death. A “disabling condition or disease” is any medically
determinable physical or mental impairment that can be expected to result in
death; or that has lasted or can be expected to last for a continuous period of
not less than 12 months; that renders you unable to engage in any substantial
gainful activities. In the case of a child under the age of 18, a disabling
condition or disease is any medically determinable physical or mental
impairment of comparable severity.
In addition, your attending physician must certify that: standard health
services or procedures have been ineffective, or would be medically
inappropriate in treating your life-threatening condition or disease; or that no
more beneficial standard treatment exists that is a covered service under the
contract.
Your attending physician must have recommended a health service or
procedure (including off-label usage of a pharmaceutical product) that, based
on at least two documents from the available medical literature, is likely to be
more beneficial to you than any standard covered health service or procedure.
To make this recommendation, your attending physician must be boardcertified or board-eligible and qualified to practice in the area appropriate to
treat your life-threatening or disabling condition or disease.
If you meet the requirements of this subparagraph and all of the requirements
of “Coverage Determinations Subject to External Appeal” above, you may
request an external appeal. “Requesting and External Appeal” below provides
information on requesting an external appeal.
(iv)External Appeal Of Determinations Involving Clinical Trials
This subparagraph governs the external appeal of determinations involving
services provided in clinical trials.
To request an external appeal under this subparagraph, your attending
physician must certify that you have a life–threatening or disabling condition
or disease as described in “Conditions for External Appeal of Determinations
Involving Experimental and/or Investigational Treatment” above. In addition,
your attending physician must certify that a clinical trial for your condition
exists and that you are eligible to participate in the clinical trial.
Your attending physician must also recommend that you participate in the
clinical trial. To make this recommendation, your attending physician must
be board-certified or board-eligible and qualified to practice in the area
appropriate to treat your life-threatening or disabling condition or disease.
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The clinical trial for which you are requesting coverage must be peerreviewed, reviewed and approved by a qualified Institutional Review Board,
and approved by one of the following:

The National Institutes of Health (NIH), and NIH cooperative group or
NIH center, the Food and Drug Administration, or the Department of
Veterans Affairs;

An entity that has been identified by the NIH as a qualified nongovernmental research entity; or

An Institutional Review Board of a facility that has a multiple project
assurance approved by the Office of Protection from Research Risks of the
NIH.
If you meet the requirements of this subparagraph and all of the requirements
of “Coverage Determinations Subject to External Appeal” above, you may
request an external appeal. “Requesting an External Appeal” below provides
information on requesting an external appeal
(v) Effect Of The External Appeal Agent’s Decision; Coverage
The decision of the External Appeal Agent is binding on both parties. If the
External Appeal Agent decides in our favor, we will not cover the requested
service. If the external appeal agent decides in your favor, we will cover the
service as follows:

For services denied as not medically necessary, we will treat the services
as medically necessary and provide coverage subject to all other
conditions of your coverage.

For services denied as experimental and/or investigational, other than
services provided in a clinical trial, we will pay for the patient costs you
incur for the services, subject to all other conditions of your coverage.

For services denied as experimental and/or investigational that are
provided in a clinical trial, we will cover the costs of health services
required to provide treatment according to the design of the trial, subject
to all other conditions of coverage. We are not required to pay for drugs
or devices that are the subject of the clinical trial.
We will not provide coverage for any service that is not a covered service
under the contract. In addition, this external appeal right does not alter your
cost-sharing responsibilities, if any, as otherwise provided for in the contract.
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(vi) Requesting An External Appeal
If you meet the conditions described in this paragraph, you may request an
external appeal by filing a standard external appeal request form with the New
York State Insurance Department. If the requested service has already been
provided to you, your physician may file an appeal on your behalf. We will
send a standard external appeal request form to you when we have made a
final adverse determination upon completion of Level One internal appeal. If
your provider requested the Level One internal appeal of a retrospective
adverse determination, we will send your provider a standard provider
external appeal request form with the notice of final adverse determination.
You or your physician may obtain additional standard request forms at any
time by calling the New York State Insurance Department at 800-400-8882 or
by accessing its website (www.ins.state.ny.us); by calling the New York
Department of Health at 518-486-6074 or by accessing its website
(www.health.state.ny.us), or by calling our Customer Service Department.
You must file your request for an external appeal with the New York
State Insurance Department within 45 days of receiving a final adverse
determination upon completion of Level One internal appeal; or within
45 days of receiving a letter from us waiving the internal review process.
We do not have the authority to grant extensions of this deadline.
A Level Two internal appeal is available to you as an alternative to external
appeal (see “Level Two internal appeal” above); our Level Two internal
appeal is optional. However, whether or not you request a Level Two internal
appeal, your application for external appeal must be filed with the New York
State Insurance Department within 45 days from your receipt of the notice of
final adverse determination upon completion of Level one internal appeal, to
be eligible for review by an external appeal agent.
You may be charged a fee of up to $50 to request an external appeal, which
may be waived if we determine that paying the fee is a financial hardship.
The fee is returned if your external appeal is successful.
If you do not understand any part of the external appeal process or if you have
questions regarding your right to external appeal, you may contact us, the
New York State Insurance Department, of the New York State Department of
Health.
We urge you, but you are not required, to exhaust all levels of the applicable
grievance procedure and/or utilization review procedure, before taking any
further action with respect to our handling of your case. If you are not
satisfied, you may contact the New York State Insurance Department at 800342-3736 at any time during the review process. Upon request, the Customer
Service Department will provide you with the appropriate address for writing
to the Insurance Department.
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C. WHEN COVERAGE ENDS
Coverage under the Plan terminates for a covered employee, retiree, and their dependents on
the:
 Date the covered individual leaves employment
 Date the covered individual ceases to be in a class of participants eligible for coverage
 Date the participant fails to make any required contribution for coverage (for the
contributory portion of the benefit)
 Date the Plan is terminated
Members will be provided with 90 days notice before termination of the Plan and 90 days
notice before termination of a specific benefit.
When your coverage ends, the Plan will provide you with a certificate that documents your
medical coverage for the previous 18 months. This certificate is required by the Health
Insurance and Portability Accountability Act of 1996 (HIPAA).
D. CONTINUATION OF COVERAGE
There are certain situations in which the coverage for the employee and his or her dependents
may be extended beyond the date in which it would normally end. These are:
1. In The Case Of A Disabled Child
Coverage may be extended beyond the age limit for a child who is incapable of selfsustaining employment by reason of mental illness, developmental disability, mental
retardation, as defined in the mental hygiene law, or physical handicap and who became
so incapable prior to the attainment of the age at which dependent coverage would
otherwise terminate and who is chiefly dependent upon such member for support and
maintenance. This is provided that the disability occurred before the age limit and the
employee was enrolled in family coverage at the time of the disability. The employee
must remain enrolled in the medical plan in order for the dependent coverage to continue.
2. Leave Without Pay
Employees who take a leave without pay may choose to continue their healthcare
coverage. However, in certain situations, if an employee is granted leave without pay,
the individual district may require that the employee pay the entire cost of the premium
for the duration of the leave. Any employee who anticipates taking a leave without pay
should consult with their local school district for further details.
3. Total Disability
If, on the day that coverage would have otherwise terminated, an employee or dependent
is covered under the medical plan and is determined to be totally disabled, that individual
may qualify for an extension of certain benefits. Benefits shall be provided during a
period of total disability for hospital confinements commencing or surgery performed
during the next 31 days for the injury, sickness or pregnancy causing the total disability.
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Benefits will be extended with respect to the sickness, injury or pregnancy which caused
the disability, of at least 12 months subsequent to termination of insurance unless
coverage is afforded for the total disability under another group plan. Total disability is
defined as any injury or illness that prevents an employee from doing a majority of the
usual duties associated with the employee’s occupation or, in the case of a dependent, any
injury that prevents the dependent from participating in a majority of the usual activities
of a person of similar age and sex.
4. Retiree Provisions
The provisions of the local individual school contract shall be subject to the following
rules and limitations:
- Coverage may be continued for a retiree and his or her eligible dependents for life, or
in the case of an eligible dependent, until he or she in no longer an eligible dependent
- In the event a retiree continues to participate in the Plan and dies, his or her spouse
may elect to continue the same coverage provided to the retiree at the time of the
retiree’s death for life
- In the event a retiree dies and his or her spouse elects to continue coverage in
accordance with the preceding paragraph, in no event may such spouse apply for the
coverage of his or her husband or wife upon remarriage.
- In the event the spouse of a retiree dies and the retiree remarries, the retiree may
apply to the Plan Sponsor for coverage of his or her new spouse, provided that:
- The retiree continues to be covered under the Plan;
- The application is made not later than 31 days after the marriage, and
- The coverage for the new spouse is not greater that the coverage provided to the
retiree.
5. As Required By COBRA
Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)- On April 7, 1986,
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) was signed into
law (Public Law 99-272, Title X). Under COBRA, most employers sponsoring group
health plans must offer covered workers and their families the opportunity for a
temporary extension of health coverage at group rates in certain instances where coverage
under the plan would otherwise end.
If you are an employee covered by the Plan, you have a right to choose continuation
coverage if you lose your group health coverage because of a reduction in your hours of
employment or the termination of your employment (for reasons other than gross
misconduct on your part).
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If you are the spouse of an employee or other worker covered by the Plan, you have a
right to choose this continuation coverage for yourself if you lose group health coverage
under the Plan for any of the following reasons:

The death of your spouse

A termination of your spouse's employment (for reasons other than gross misconduct)
or reduction in your spouse's hours of employment

Divorce or legal separation from your spouse

Your spouse becomes entitled to Medicare
In the case of a dependent child of an employee or other worker covered by the Plan, the
child has the right to continuation coverage if group health coverage under the Plan is lost
for any of the following reasons:

The death of a parent

The termination of a parent's employment (for reasons other than gross misconduct)
or reduction in a parent's hours of employment with the employer

Parents' divorce or legal separation

A parent becomes entitled to Medicare

The dependent ceases to be a "dependent child" under the Plan
Under COBRA, the covered worker or a family member has the responsibility to inform
the plan administrator of a divorce, legal separation, or a child losing dependent status
under the Plan. Such notice must be made within 60 days of the event or the date on
which coverage would be lost because of the event. The employer has the responsibility
to notify the plan administrator of the covered worker's death, termination of employment
or reduction in hours, or entitlement to Medicare.
Health care continuation rights also are available to covered retirees, their spouses, and
widows or widowers of covered retirees, if they should lose group health coverage in the
event that the employer should ever file for bankruptcy.
When the plan administrator is notified that one of the above named events has happened,
the plan administrator will in turn notify you that you have the right to choose
continuation coverage. Under the COBRA law, you have at least 60 days from the date
you would lose coverage because of one of the events described above to inform the plan
administrator that you want continuation coverage.
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If you do not choose continuation coverage, your group health insurance coverage will
end.
If you choose continuation coverage, the employer is required to give you coverage
which, as of the time coverage is being provided, is identical to the coverage provided
under the plan to similarly situated employees or family members. The COBRA law
requires that you be afforded the opportunity to maintain continuation coverage for 36
months (i.e., 3 years) unless you lost group health coverage because of a termination of
employment or reduction in hours. In that case, the required continuation coverage period
is 18 months. The 18-month period may be extended to 36 months if a second event (e.g.,
divorce, legal separation, death, or Medicare entitlement) occurs during that 18-month
period.
Note: If a qualifying event occurs less than 18 months after the date an employee
becomes entitled to Medicare benefits, the coverage period for qualified beneficiaries
other than the employee is extended to 36 months from the date of the employee's
Medicare entitlement. Moreover, the 18-month period may be extended for an additional
11 months (for a total of 29 months) if an individual is determined to be disabled (under
the rules for Social Security disability benefits) and the plan administrator is notified of
that determination within 60 days. The affected individual also must notify the plan
administrator when it is determined (for purposes of Social Security disability benefits)
that the individual is no longer disabled.
The COBRA law provides that your continuation coverage may be cut short of the full
coverage period – 18, 29, or 36 months – for any of the following reasons:

the employer no longer provides group health coverage to any of its employees

the premium for your continuation coverage is not paid

you become covered under another group health plan that does not contain any
provision restricting or limiting coverage of a "preexisting medical condition"

you become entitled to Medicare

there has been a final determination that you are no longer disabled, for beneficiaries
who qualified for an extra 11 months continuation coverage based on their disability
at termination or within the first 60 days.
You do not have to show that you are insurable to choose continuation coverage.
However, under the COBRA law, you may have to pay all or part of the premium for
your continuation coverage. Generally, for the 18 or 36 month continuation coverage
period, you may be required to pay a maximum of 102% of the premium. If you are
entitled to continuation coverage due to a disability, then for months 19 through 29, you
may be required to pay 150% of the premium. A minimum 30-day "grace period" will be
allowed for you to pay your regularly scheduled premiums. (COBRA also provides that
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at the end of the 18, 29, or 36 month continuation coverage period you must be allowed
to enroll in an individual conversion health plan provided under the Plan).
If you have any questions about COBRA, or you or your spouse have changed address,
please contact the plan administrator.
E. COORDINATION OF BENEFITS
You or a covered family member may be entitled to benefits under another group health plan
(such as a plan sponsored by your spouse's employer) that pays part or all of your medical
treatment costs. If this is the case, benefits from the Plan will be "coordinated" with the
benefits from the other plan so that the combined reimbursement does not exceed the Plan’s
normal benefit payment, up to any Plan maximums.
In addition to having your benefits coordinated with other group medical or dental plans,
benefits from this Plan are coordinated with "no fault" automobile insurance (and any
payments recoverable under any Workers' Compensation law, Occupational Disease law or
similar legislation.)
1. How Coordination Of Benefits Works
When benefits are payable from more than one plan, the plan that pays benefits first is
considered the "primary" plan. The plan that next pays is considered the "secondary" plan.
The primary plan must pay or provide its benefits as if the secondary plan or plans did not
exist. A secondary plan may take the benefits of another plan into account only when, under
these rules, it is secondary to that other plan.
When there is a basis for a claim under more than one plan, a plan with a coordination of
benefits provision complying with this section is a secondary plan which has its benefits
determined after those of the other plan, unless the other plan has a COB provision
complying with this section in which event the order of benefit determination rules will
apply.
The order of benefit payments is determined using the first of the following rules which
applies:
(i)
the benefits of a plan which covers the person as an employee, member or subscriber
(that is, other than as a dependent) are determined before those of a plan which covers
the person as a dependent;
(ii)
except as stated below, when a plan and another plan cover the same child as a
dependent of different persons, called parents:
(a)
the benefits of the plan of the parent whose birthday falls earlier in a year
are determined before those of the plan of the parent whose birthday falls
later in that year; but
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(b)
(c)
(d)
if both parents have the same birthday, the benefits of the plan which
covered the parent longer are determined before those of the plan which
covered the other parent for a shorter period of time;
if the other plan does not have the rule described above, but instead has a
rule based upon the gender of the parent, and if, as a result, the plans do
not agree on the order of benefits, the rule in the other plan will determine
the order of benefits;
the word birthday refers only to month and day in a calendar year, not the
year in which the person was born.
If the specific terms of a court decree state that one of the parents is responsible for the health
care expenses of the child, and the entity obligated to pay or provide the benefits of the plan
of that parent has actual knowledge of those terms, the benefits of that plan are determined
first. The aforementioned does not apply with respect to any claim determination period or
plan year during which any benefits are actually paid or provided before the entity has that
actual knowledge.
The benefits of a plan which covers a person as an employee who is neither laid off nor
retired (or as that person’s dependent) are determined before those of a plan which covers
that person as a laid off or retired employee (or as that employee’s dependent). However, if
the other plan does not have this rule, and if, as a result, the plans do not agree on the order of
benefits, the preceding sentence is ignored.
If none of the above rules determines the order of benefits, the benefits of the plan which
covered an employee, member or subscriber longer are determined before those of the plan
which covered that person for the shorter time.
To determine the length of time a person has been covered under a plan, two plans shall be
treated as one if the claimant was eligible under the second within 24 hours after the first
ended. Thus, the start of a new plan does not include:
• a change in the amount or scope of a plan’s benefits;
• a change in the entity which pays, provides or administers the plan’s benefits; or
• a change from one type of plan to another (such as, from a single employer plan to that of
a multiple employer plan).
The claimant’s length of time covered under a plan is measured from the claimant’s first date
of coverage under that plan. If that date is not readily available, the date the claimant first
became a member of the group shall be used as the date from which to determine the length
of time the claimant’s coverage under the present plan has been in force.
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F. ADMINISTRATION
1. Name Of Plan:
Chautauqua County School Districts’ Medical Health Plan
2. Plan Year:
The Plan Year end is June 30th
3. Plan Sponsor And Plan Administrator:
The Plan is maintained by the Cooperative Members of the Chautauqua County School
Districts’ Medical Health Plan Cooperative.
4. Employee Identification Number (EIN):
The EIN for this plan is 16-1278979
5. Plan Number:
The plan number for Medical Coverage is 001
The plan number for Dental Coverage is 002
The plan number for Vision Coverage is 003
The plan number for Prescription Coverage is 004
6. Type Of Plan:
The Plan is a Group Health Plan subject to Article 47 of NYS Insurance Law
7. Type Of Administration:
The Plan is a municipal cooperative risk-sharing health benefits plan which obtains and
maintains a certificate of authority from the New York State Superintendent of Insurance
pursuant to the provisions of Article 47. Funds for payment of health claims are paid into
a Cooperative from which claims are paid. All funds received by the Cooperative shall
be applied toward payment of claims and reasonable expenses for administration of the
Plan. In addition, insured premiums for service-type hospital benefits and stop-loss
insurance are paid by this Cooperative.
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8. Agent for Service Of Legal Process:
The agent for service of legal process is Richard Kaiser at Hodgson, Russ, Andrews,
Woods, & Goodyear located at 1 M & T Plaza, Buffalo NY 14203, 716 856-4000. The
service of legal process may be made upon a Plan Cooperative Member or the plan
administrator.
9. Cooperative Members:
Cooperative Members are superintendents of the following school districts:
Bemus Point Central School
3980 Dutch Hollow Road
Bemus Point, NY 14712
Falconer Central Schools
2 East Avenue
Falconer, NY 14733
Erie 2-Chautauqua-Cattaraugus BOCES
8685 Erie Road
Angola, NY 14006
Fredonia Central Schools
East Main Street
Fredonia, NY 14063
Brocton Central Schools
138 West Main Street
Brocton, NY 14716
Frewsburg Central Schools
26 Institute Street
Frewsburg, NY 14738
Cassadaga Valley Central Schools
P.O. Box 540, Route 60
Sinclairville, NY 14782
Jamestown Public Schools
201 East 4th Street
Jamestown, NY 14701
Chautauqua Lake Central Schools
100 North Erie Street
Mayville, NY 14757
Panama Central Schools
41 North Street
Panama, NY 14767
Clymer Central Schools
P.O. Box 580, East Main Street
Clymer, NY 14724
Pine Valley Central School
7755 Rt. 83
South Dayton, NY 14138
Dunkirk City Schools
620 Marauder Drive
Dunkirk, NY 14048
Ripley Central Schools
P.O. Box 688, 12 North State Street
Ripley, NY 14775
Silver Creek Central Schools
P.O. Box 270
Silver Creek, NY 14136
Sherman Central Schools
P.O. Box 950, 127 Park Street
Sherman, NY 14781
Westfield Central Schools
203 East Main Street
Westfield, NY 14787
Southwestern Central Schools
600 Hunt Road, W.E.
Jamestown, NY 14701
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10. Insurance:
Blue Cross/Blue Shield of Western New York provides claim payment services for
medical benefits. Benefits are paid through contributions to the Cooperative.
Express Scripts, Inc. provides claims payment services for prescription drug coverage
available through the prescription drug card plan. Benefits are paid through contributions
to the Cooperative.
The Guardian Life Ins. Company provides claim payment services for dental benefits.
Benefits are paid through contributions to the Cooperative.
Vision Service Plan provides claims payment services for vision care coverage. Benefits
are paid through contributions to the Cooperative and Vision Service Plan has agreed to
adjudicate claims.
The addresses of the organizations listed above are as follows:
Medical Plan Supervisor and
Prescription Plan Supervisor for Prescriptions under the Extended Medical Plan
Blue Cross & Blue Shield of Western New York
1901 Main Street
PO Box 80
Buffalo NY 14240-0080
1-800-888-0757
Prescription Plan Supervisor (Except for Prescriptions covered under the Extended
Medical Plan)
Express Scripts
4700 Nathan Lane North
Plymouth MN 55442
1-877-432-8978
Vision Plan Supervisor
Vision Service Plan
Attn: Non-Member Doctor Claims
P.O. Box 997105
Sacramento, CA 95899-7105
1-800-877-7195
Dental Plan Supervisor
Guardian Dental Claims
PO Box 2459
Spokane, WA 99210-2459
1-888-278-4542
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11. Right to Receive and Release Necessary Information
For the purpose of determining the applicability of and implementing the terms and
provisions of this plan or any provision of similar purpose of any other Plan, the Plan
supervisor may, without the consent of, or giving notice to any person, release to or
obtain from any insurance company or other organization or person any information, with
respect to any person claiming benefits under the plan shall furnish the Plan Supervisor
such information as may be necessary to implement this provision.
Whenever payments which should have been made under this plan in accordance with the
above provision have been made under any other plans, the Plan Supervisor will have the
right to pay to any organizations making these payments any amount it determines to be
warranted in order to satisfy the intent of the above provisions, and amounts paid in this
manner will be considered to be benefits paid under this Plan and, to the extent of these
payments, the Plan Supervisor and the Plan Sponsor will be fully discharged from
liability under this Plan.
12. Reimbursement Provision
If a covered member is injured through the act or omission of another person, the benefits
of this plan shall be provided only if the employee shall agree in writing:
 To reimburse the Plan to the extent of the benefits provided, immediately upon
collection of damages by him/her, whether by legal action, settlement, or otherwise,
and:
 To provide the Plan with a lien and order directing reimbursement of medical
payments, to the extent of benefits provided by the Plan. The lien and order may be
filed with the person whose act caused the injuries, his agent or carrier, the court, or
the attorney of the employee.
A representative of the Plan shall have the right to intervene in any suit or other
proceeding to protect the reimbursement right hereunder. The covered individual shall be
responsible for all fees of the attorney handling the claim against the third party.
13. Right of Recovery
Whenever payments have been made by the Plan Supervisor with respect to allowable
expenses in a total amount which is, at any time, in excess of the maximum amount of
payment necessary at that time to satisfy the intent of this provision, the Plan Supervisor
shall have the right to recover such payments, to the extent of such excess, from one or
more of the following, as the Plan supervisor shall determine:
 Any person, to, or for, or with respect to whom such payments are made:
 Any insurance company; and
 Any other organization of the type which provides services, or pays any benefits of
the kind defined within this plan.
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14. Subrogation
If any expenses are covered under this Plan arise from acts or omissions for which a third
party may be legally liable for, and if such third party fails or refuses to make prompt
payment of such damages, then the Plan may pay for such benefits or services as are
provided herein, and the Plan shall thereupon be subrogated to any claims which any
covered person may have against such third party causing the covered expense to the
extent of such payment and if the covered person collects the sum as damages from such
third party, whether by action settlement, or any other manner, such covered person shall
be liable to the Plan for the amount of all payments so made by this plan
G. STATEMENT OF ERISA RIGHTS
As a participant in Chautauqua County School Districts’ Medical Health Plan you are
entitled to certain rights and protections under the Employee Retirement Income Security Act
of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the plan administrator’s office and at other specified locations,
such as worksites and union halls, all documents governing the plan, including insurance
contracts and collective bargaining agreements, and a copy of the latest annual report (Form
5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public
Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain, upon written request to the plan administrator, copies of documents governing the
operation of the plan, including insurance contracts and collective bargaining agreements,
and copies of the latest annual report (Form 5500 Series) and updated summary plan
description. The administrator may make a reasonable charge for the copies.
Receive a summary of the plan’s annual financial report. The plan administrator is required
by law to furnish each participant with a copy of this summary annual report.
Continue Group Health Plan Coverage
Continue health care coverage for yourself, spouse or dependents if there is a loss of
coverage under the plan as a result of a qualifying event. You or your dependents may have
to pay for such coverage. Review this summary plan description and the documents
governing the plan on the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for preexisting conditions
under your group health plan, if you have creditable coverage from another plan. You should
be provided a certificate of creditable coverage, free of charge, from your group health plan
or health insurance issuer when you lose coverage under the plan, when you become entitled
to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if
you request it before losing coverage, or if you request it up to 24 months after losing
coverage. Without evidence of creditable coverage, you may be subject to a preexisting
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condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in
your coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants ERISA imposes duties upon the people
who are responsible for the operation of the employee benefit plan. The people who operate
your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest
of you and other plan participants and beneficiaries. No one, including your employer, your
union, or any other person, may fire you or otherwise discriminate against you in any way to
prevent you from obtaining a (pension, welfare) benefit or exercising your rights under
ERISA.
Enforce Your Rights
If your claim for a (pension, welfare) benefit is denied or ignored, in whole or in part, you
have a right to know why this was done, to obtain copies of documents relating to the
decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you
request a copy of plan documents or the latest annual report from the plan and do not receive
them within 30 days, you may file suit in a Federal court. In such a case, the court may
require the plan administrator to provide the materials and pay you up to $110 a day until you
receive the materials, unless the materials were not sent because of reasons beyond the
control of the administrator. If you have a claim for benefits which is denied or ignored, in
whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with
the plan’s decision or lack thereof concerning the qualified status of a domestic relations
order or a medical child support order, you may file suit in Federal court. If it should happen
that plan fiduciaries misuse the plan’s money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you
may file suit in a Federal court. The court will decide who should pay court costs and legal
fees. If you are successful the court may order the person you have sued to pay these costs
and fees. If you lose, the court may order you to pay these costs and fees, for example, if it
finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about your plan, you should contact the plan administrator. If you
have any questions about this statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the plan administrator, you should contact the nearest
office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed
in your telephone directory or the Division of Technical Assistance and Inquiries, Pension
and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue
N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights
and responsibilities under ERISA by calling the publications hotline of the Pension and
Welfare Benefits Administration.
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SECTION VII
POINT OF SERVICE
MEDICAL PLAN
(MANAGED CARE OPTION)
POS
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Subject to the approval of NYS Insurance Department
A. SUMMARY OF MEDICAL BENEFITS
1. Description of Point of Service
The plan administrator has contracted with selected healthcare providers to render
quality medical care at agreed fees. There are financial incentives to the participant and
the Plan when these in-network providers are utilized. A list of in-network providers is
provided separately from this booklet and is available at your School Business Office.
For example, when in-network providers are utilized, the plan pays for office visits at
100% with a $10 copayment. Payment for an out-of-network provider will be paid at
80% of the Schedule of Allowances subject to the annual deductible.
With the exception of emergency treatment due to an accident or life threatening illness,
you must get a referral from an in-network primary care physician for your
expenses to be paid at the in-network benefit level; otherwise they will be treated as
out-of-network. Additionally, the out-of-network benefit level will be paid for all claims
submitted by any out-of-network providers regardless of where you live or your ability
to access in-network providers.
2. Out-of-Network Benefits are subject to Deductible and Co-insurance
a. Deductible
Each calendar year, before the Plan pays out-of-network benefits, you must satisfy
an annual deductible: $250 individual / $500 family.
b. How the Family Deductible Works
The family deductible is designed to limit a family's annual outlay for covered
expenses before the Plan begins to pay benefits. Each family member's (including a
newborn's) covered expenses up to his or her per person deductible count toward the
family deductible. Once this family deductible is met, the Plan will begin to pay
benefits for all family members, including those who have not yet incurred expenses.
The Plan will also pay applicable benefits for any covered family member who meets
the individual deductible, even if the total family deductible has not yet been met.
If two or more covered persons from the same family are injured in the same
accident, only one deductible will be applied each year against the expenses incurred
as a result of that accident.
c. 80% Reimbursement
POS
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Subject to the approval of NYS Insurance Department
After you have met your deductible the Plan reimburses 80% of most out-of-network
expenses. There are some specific exceptions to this rule that are described under
specific benefit categories.
d. Out-of-Pocket Limit
Except as provided below, this is a cap on the amount of unreimbursed covered
medical expenses you will have to pay in any one year. Once you reach your out-ofpocket limit, the Plan will pay 100% of the Schedule of Allowances for that year.
Most unreimbursed covered expenses for both you and your covered family
members count toward your out-of-pocket limit. Unreimbursed covered expenses
include deductible and coinsurance amounts-but do not include amounts your
physician or health care provider may charge above the Schedule of Allowances
or amounts exceeding Plan limits. Mental health and chemical abuse or
dependence charges in excess of what the Plan reimburses will not be applied toward
meeting your Out-of-Pocket limit. Prescription drug copayments do not apply to
meeting the limit.
In any calendar year, the Plan limits each participant’s out-of-pocket expenses to
$2,000 per participant or $4,000 per family. As an example, to meet the individual
out-of-pocket limit of $2,000, you generally must incur a total of $10,000 in covered
medical expenses. Of this $10,000you will pay $250 to meet your deductible and
then 20% of each remaining covered expense until the total amount you have paid
equals $2,000. Thus, in this example the total payment that you would be responsible
for is equal to $2,000 ($250 deductible + $1,750 out-of-pocket limit. Once the family
out-of-pocket limit is reached, all benefits (except for the limitations indicated
above) will be paid at 100% for all family members including those who have not yet
incurred any expenses.
3.
Covered Benefits
a. Physician Office Visits
In-network, after a $10 copayment, the Plan pays 100% of covered charges for office
visit services provided by a physician, licensed physician’s assistant or nurse
practitioner. Out-of-network, the Plan pays 80% of the Schedule of Allowances after
the deductible for these services
Page 2
a. Inpatient Hospital Care
POS
10/01/02
Subject to the approval of NYS Insurance Department
In-network, the Plan pays 100% of covered charges. Out-of network, the Plan pays
80% of the Scheduled of Allowances after the deductible for these services.
The following services are covered services under the Inpatient Hospital benefit:
 Bed, board and general nursing services in a semi-private room, up to 365 days
per confinement. A semi-private room is a room that the hospital considers to be
semi-private. If you occupy a private room in a participating hospital, the Plan
will cover up to the average charge for a semi-private room.
 Bed, board and general nursing services in a private room, if such room is
deemed to be medically necessary
 Use of operating, recovery and cystoscopic rooms and equipment.
 Use of intensive care or special care units and equipment.
 The administration and use of drugs, medications, sera, vaccines, intravenous
preparations to the extent these items are commercially available and readily
obtainable by the hospital.
 Dressings and plaster casts.
 Professional and equipment services in connection with the services listed below
under the condition that the services are provided by a hospital employee and the
charge for the services is payable to the hospital:
– Oxygen
– Physiotherapy
– Laboratory and pathological examinations
– Radiation therapy
– Chemotherapy
 Use of equipment and supplies in connection with the services listed below.
Physician charges or professional fees charges for the following services are not
covered under the Basic Benefits portion of the medical plan, but can be
submitted to the Extended Medical portion for reimbursement:
– Anesthesia
– Electrocardiograms
– Electroencephalograms
– X-ray examinations
 Blood products, except when participation in a volunteer blood replacement
program is available to you.
 Any additional medical services and supplies which are customarily provided by
hospitals.
 Bed, board, general nursing services, the use of equipment and supplies in
connection to a hospital stay for such period as is determined by the attending
physician in consultation with the patient to be medically appropriate after such
covered person has undergone a lymph node dissection or a lumpectomy for the
treatment of breast cancer or a mastectomy covered by the Plan. Coverage for the
length of stay in the hospital may not be restricted in a manner which is
inconsistent with the coverage provided to the portion of the stay that preceded
the lymph node dissection, lumpectomy or mastectomy.
Page 3
b. Emergency Care
POS
10/01/02
Subject to the approval of NYS Insurance Department
After a $50 copayment, the Plan pays for 100% of covered charges for life
threatening emergencies. The copayment is waived if you are admitted to the
hospital. An additional $50 copayment is required for non-emergency use of the
emergency room.
c. Care in Connection with a Surgery
In-network, the Plan pays for 100% of covered charges for facility and medical
equipment services with no deductible for outpatient surgical procedures. Out-ofnetwork the Plan pays 80% of the Schedule of Allowances after the deductible for
these services.
d. Pre-Admission Testing
In-network, the Plan will pay 100% of covered charges with no deductible. Out-ofnetwork, the Plan will pay 80% of the Schedule of Allowances after payment of the
deductible. The Plan covers tests ordered by a physician which are given to you
before your admission to the hospital as a registered bed patient for surgery provided
the following conditions are met:
 They are necessary for and consistent with the diagnosis and treatment of the
condition for which surgery is to be performed;
 You have made a reservation for the hospital bed and for the operating room
before the tests are given;
 You are physically present at the hospital when the tests are given;
 Surgery actually takes place within 7 days after the tests were given.
e. Home Care
In-network, after a $10 copayment the Plan pays 100% of covered charges. Out-of
network, the Plan will pay 80% of the Schedule of Allowances after payment of the
deductible. Covered charges include services for care received in your home by
certified Home Care agencies (as determined by New York State Public Health Law)
under the following conditions:
 If you did not receive Home Care visits, you would have to be hospitalized in a
hospital or cared for in a skilled nursing facility.
 A plan for your Home Care is established and approved in writing by a
physician.
The following services are considered covered expenses under the Home Care
benefit:
 Part-time or intermittent home nursing care by or under the supervision of a
registered professional nurse (RN).
 Part-time or intermittent home health aide services which consist primarily of
caring for the patient.
 Physical, occupational or speech therapy if the Home Care Agency or hospital
provides these services.
Page 4
 Medical supplies, drugs and medications prescribed by a doctor, but only if these
items are covered if you are confined in a hospital or skilled nursing facility.
POS
10/01/02
Subject to the approval of NYS Insurance Department


Laboratory services provided by or on behalf of the Home Care Agency or
hospital;
Up to 365 visits in each calendar year. Each visit by a member of a Home Care
team is counted as one Home Care visit. Four hours of home health aide service
is counted as one Home Care visit.
f. Ambulance
In-network, medically necessary transportation in an ambulance is covered at 100%
after a $50 copayment. There is no out-of-network benefit; you will be responsible
for the entire cost.
g. Inpatient Mental Health
In-network, the Plan pays 100% of covered charges for acute care. Participants must
obtain pre-authorization by the Plan’s mental health benefit manager to be eligible
for coverage. The Plan’s mental health benefit manager must also coordinate the care
that is provided. Out-of-network, the Plan pays 80% of the Schedule of Allowances
after the deductible for acute care. Coverage is limited to a combined total of 30 days
per member per year whether in-network or out-of network.
h. Inpatient Alcohol and Substance Abuse
In-network, the Plan pays 100% of covered charges for inpatient detoxification. Outof network, the Plan pays 80% of the Schedule of Allowances for inpatient
detoxification after the deductible Coverage is limited to a combined total of 30 days
per member per year whether in-network or out-of network.
i. Laboratory
In-network, the Plan pays 100% of covered charges, without a deductible, for each
laboratory examination performed in connection with the diagnosis of an injury or
illness at a participating facility. Out-of-network, the Plan pays 80% of the Schedule
of Allowances after the deductible, up to a maximum of $100 per participant per
year.
j. Physicals
In-network, after a $10 copayment, the Plan pays 100% of covered charges, without
a deductible, for routine physicals. There is no out-of-network benefit; you will be
responsible for the entire cost.
Page 5
k. Skilled Nursing Facility
POS
10/01/02
Subject to the approval of NYS Insurance Department
In-network, the Plan pays 100% of covered charges, without a deductible, subject to
pre-authorization by the Plan. Out-of network, the plan pays 80% of the Schedule of
Allowances after the deductible. Coverage is limited to a combined total of 50 days
per member per year whether in-network or out-of network.
l. Eye Care
In-network, after a $10 copayment, the Plan pays 100% of medically necessary
charges. Out-of-network, the Plan pays 80% of the Schedule of Allowances after the
deductible for medically necessary eye care.
m. Prosthetic Devices
In-network, the Plan pays 100% of charges for internal prostheses and postmastectomy prosthetics. Out-of-network, internal prostheses are covered as part of
the inpatient hospital benefit. Out-of-network, the Plan pays 80% of the Schedule of
Allowances after the deductible for post-mastectomy prosthetics.
n. Outpatient Mental Health Treatment
In-network, the Plan pays 50% of covered expenses, up to 20 visits per year for
outpatient mental health care. Participants must obtain pre-authorization by the
Plan’s mental health benefit manager to be eligible for coverage. The Plan’s mental
health benefit manager must also coordinate the care that is provided. Out-ofnetwork, the Plan pays 50% of the Schedule of Allowances after the deductible.
Coverage is limited to a combined total of 20 visits per member per year whether innetwork or out-of network.
o. Outpatient Chemical Abuse or Dependence Treatment
In-network, after a $10 copayment, the Plan pays 100% of covered expenses, up to
60 visits per year for outpatient alcohol and substance abuse treatment. Up to 20 of
the 60 visits may be used for family therapy. Participants must obtain preauthorization by the Plan’s mental health benefit manager to be eligible for coverage.
The Plan’s mental health benefit manager must also coordinate the care that is
provided.
Out-of network, the Plan pays 80% of the Schedule of Allowances after the
deductible for covered services, up to 60 visits per year, 20 of which may be for
family therapy. Coverage is limited to a combined total of 60 visits per member per
year whether in-network or out-of network.
Page 6
p. Physician Surgical Fees
POS
10/01/02
Subject to the approval of NYS Insurance Department
In-network, the plan pays 100% of covered charges for surgical services provided by
a physician, second surgical opinions, and anesthesia services. Out-of-network, the
Plan pays 80% of the Schedule of Allowances after the deductible for these services.
Breast Reconstruction After a Mastectomy
In-network, the plan pays 100% of covered charges for breast reconstruction
after a mastectomy including all stages of reconstruction of the breast on
which the mastectomy has been performed; and surgery and reconstruction of
the other breast to produce a symmetrical appearance. Out-of-network, the
Plan pays 80% of the Schedule of Allowances after the deductible for these
services.
q. Physician Maternity Fees
In-network, the plan pays 100% of covered charges for maternity services provided
by a physician, except the initial office visit to determine pregnancy requires a $10
copayment. Out-of-network, the Plan pays 80% of the Schedule of Allowances after
the deductible for these services.
r. Well-Child Care
In-network, the plan will cover at 100% of covered charges. Out-of network, but at a
Participating Provider (within the broader BCBS network but not in the Point-ofservice network), the Plan pays 100% of the Schedule of Allowances. For nonparticipating providers, the Plan pays 80% of the Schedule of Allowances after the
deductible.
The following services rendered to a covered dependent from the date of birth
through the attainment of nineteen years of age are covered by this benefit:



an initial hospital check-up and well-child visits scheduled in accordance
with the prevailing clinical standards of a national association of pediatric
physicians;
at each visit, a medical history, a complete physical examination,
developmental assessment, anticipatory guidance, appropriate immunizations
and laboratory tests;
necessary immunizations for diphtheria, pertussis, tetanus, polio, measles,
rubella, mumps, haemophilus influenzae type b and hepatitis b.
Page 7
s. Other Covered Services
POS
10/01/02
Subject to the approval of NYS Insurance Department
In-network, the plan pays 100% with no deductible for covered charges after a $10
co-payment. Out-of-network, the Plan pays 80% of the Schedule of Allowances after
the deductible for the covered charges.
The following services are covered:
(2) Allergy Treatment and Testing
(2) Second Cancer Opinion
A second medical opinion by an appropriate specialist, including but not limited
to a specialist affiliated with a specialty care center for the treatment of cancer.
(3) Chiropractic Care
Chiropractic care in connection with the detection or correction by manual or
mechanical means of structural imbalance, distortion or subluxation in the human
body for the purpose of removing nerve interference, and the effects thereof,
where such interference is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column. Prior authorization is required from the
Plan for coverage of out-of-network services.
(4) Diabetes
The following diabetes equipment and supplies when medically necessary: blood
glucose monitors and blood glucose monitors for the legally blind, data
management systems, test strips for glucose monitors and visual reading and
urine testing strips, insulin, injection aids, cartridges for the legally blind,
syringes, insulin pumps and appurtenances thereto, insulin infusion devices, and
oral agents for controlling blood sugar. Certain items are subject to prior
approval.
Diabetes self-management education when medically necessary. Education
provided by a certified diabetes nurse educator, certified nutritionist, certified
dietitian or registered dietitian may be limited to group settings wherever
practicable. Coverage also includes home visits when medically necessary.
(5) Diagnostic X-ray Coverage
Each laboratory examination and x-ray examination performed in connection
with the diagnosis of an injury or illness.
(6) Routine Mammogram and Pap Smear
The following services:
 an annual cervical cytology screening for cervical cancer and its precursor
states for women aged eighteen and older. The screening shall include an
annual pelvic examination, collection and preparation of a Pap smear, and
laboratory and diagnostic services provided in connection with examining
and evaluating the Pap smear;
Page 8
POS
10/01/02
Subject to the approval of NYS Insurance Department

Routine mammograms are covered for women with a past history or family
history of breast cancer upon the recommendation of a physician.
Additional mammograms covered as follows:
- One baseline mammogram for women age 35-39
- One mammogram every two years, or more frequently at the request
of a physician, for women age 40-49
- Annual mammograms for women age 50 or older
These benefits are available as an outpatient or in a physician’s office.
(7) Other Services
The following health care services when medically necessary:

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4.
Blood (including transfusion and the cost of whole blood and blood
components)
Cardiac rehabilitation
Chemotherapy
Dialysis
Hospice
Rehabilative therapy (physical, occupational, and speech therapy) - limited to
20 aggregate visits per calendar year
Podiatry (when medically necessary only. Routine foot care not covered)
Private duty nursing (subject to prior authorization)
Radiation therapy
Respiratory therapy
Pregnancy And Maternity
Group health plans and health insurance issuers, under New York State law, must
provide maternity care coverage which, other than coverage for perinatal
complications, shall include inpatient hospital coverage for the mother and newborn
child for at least 48 hours after childbirth for any delivery other than a caesarian
section and for at least 96 hours following a caesarian section. Such coverage for
maternity care shall include the services of a midwife licensed pursuant to New York
State law and affiliated or practicing in conjunction with a facility licensed pursuant
to Article 28 of the Public Health law. In accordance with New York State law the
Plan is not required to pay for duplicative routine services actually provided by both
a licensed midwife and physician. The maternity care coverage shall include parent
education, assistance and training in breast or bottle feeding, and the performance of
any necessary maternal and newborn clinical assessments. The mother shall have the
option to be discharged earlier than the time periods stated earlier in this paragraph.
In such case, the inpatient hospital coverage includes one home care visit, which is in
addition to, rather than in lieu of, any other home care coverage available in the Plan.
The home care visit may be requested any time within 48 hours of the time of
delivery (96 hours for a caesarian section) and shall be delivered within 24 hours
Page 9
POS
10/01/02
Subject to the approval of NYS Insurance Department
after discharge or the mother’s request, whichever is later. Coverage under the
maternity benefit also includes the care and treatment for, at a minimum, two
prenatal visits and separate coverage for the delivery and postnatal care.
B. MEDICAL PLAN EXCLUSIONS
The following are not covered expenses under the Medical Plan:
 Travel expenses
 Volunteer Ambulance for which there is normally not a charge
 Cosmetic services and procedures (except for reconstructive surgery when it is incidental
to or follows surgery resulting from trauma, infection or other diseases of the involved
body part or reconstructive surgery because of congenital disease or anomaly of a
covered dependent child which has resulted in a functional defect)
 Routine physicals and examinations including all laboratory and x-ray charges unless
otherwise stated
 Services or care in connection with toenails (except full removal), corns, calluses; weak,
strained or flat feet; fallen arches; instability or imbalance of the foot
 Marriage or vocational counseling
 Television, telephone, or personal comfort items
 Services rendered for bed rest, custodial care or convenience reasons
 Special clothing, including orthopedic shoes
 Personal hygiene items
 Household equipment
 Special food, diets, and food supplements (except for enteral formulas and modified
solid food products)
 Equipment repairs and adjustments, unless due to a physical change
 Routine eye examinations, eyeglasses and contact lenses, except following cataract
surgery or injuries sustained while covered by the Plan, in which case benefits will be
available for the contact lenses or regular lenses exclusive of frames
 Hearing aids
 Services covered under the Federal Employer’s Liability Act, Worker’s Compensation
Act or similar legislation, or under a No-Fault Insurance Policy
 Services for which there is no cost to the member
 Research or experimental procedures including services and equipment unless directed
pursuant to external review
 Acupuncture
 Hypnosis
 Costs incurred while under an act-of-war
 Injuries or illness arising from the commission of a felony
 Any services or care for which coverage is available in whole or in part under the basic
contracts, or riders, if any
 Services furnished to the covered person before the effective date of their coverage
Page 10
POS
10/01/02
Subject to the approval of NYS Insurance Department


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


Charges incurred for treatment on or to the teeth, the nerves or roots of the teeth,
gingival tissue, alveolar processes, treatment to the repair or the replacement of a denture
or other dental treatment; however, benefits will be payable for the surgical and the
anesthesia charges incurred for the removal of impacted teeth, or for such care or
treatment due to accidental injury to sound, natural teeth within 12 months of the
accident or a congenital disease or anomaly
Any deductibles or coinsurance under the Plan
Elective abortions
Services which are not medically necessary
Charges in excess of the Schedule of Allowances.
Care or treatment for which payment is made by any local, state, or federal government
agency, including Medicare
Professional services performed by a member of the covered person’s immediate family
Massage Therapy except when deemed to be medically necessary by a physician and
performed in the office of a physician or chiropractor.
C. SUMMARY OF PRESCRIPTION DRUG BENEFITS
a. Prescription Drug Card Plan
There are three options for the Prescription Drug Card Plan. The option available to
you depends on the terms and conditions of your individual districts. Each of the
options described below show the amount you pay for each prescription:

Option 1:
Retail (up to a 30 day supply): $7.00 (generic drugs) / $15.00
(brand name drugs) copay per prescription
Mail Order(up to a 90 day supply) $14.00 (generic drugs) / $30.00
(brand name drugs) copay per prescription

Option 2:
Retail (up to a 30 day supply): $5.00 (generic drugs) / $10.00
(preferred brand name drugs) / $25.00 (other brand name drugs)
copay per prescription
Mail Order(up to a 90 day supply) $10.00 (generic drugs) / $20.00
(preferred brand name drugs) / $50.00 (other brand name drugs)
copay per prescription
Prior authorization is required from the Plan for certain drugs. Some drugs have
specific quantity limits. A list of the specific drugs that are subject to these
restrictions is available from the plan administrator.
Under the Prescription Card Plan, you will receive a separate Prescription Plan ID
card from the Prescription Plan Supervisor.
Claims for prescription drug copayments cannot be submitted for coverage under the
medical plan.
Page 11
POS
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Subject to the approval of NYS Insurance Department
D. PRESCRIPTION DRUG EXCLUSIONS
No coverage under the prescription drug benefit will be made for the following:
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

Drugs which do not require a written prescription, except insulin
Mechanical devices such as artificial appliances and therapeutic devices
Administration or injection of any drug
Vitamins, diet supplements, and similar items (except for prenatal vitamins, enteral formulas and
modified solid food products)
Drugs which are designated by Federal or New York State Law as experimental or
investigational unless directed pursuant to external appeal
Blood or plasma
Drugs dispensed to an enrollee while a hospital patient
Drugs dispensed to an enrollee while a patient at a nursing home or institution, if cost of the drug
is billed by the nursing home or institution
Drugs available under any Federal or State Law including any Worker’s Compensation Act or
similar law (except Medicaid)
E. KEY TERMS
Following are additional words and phrases used in this document with the definition or explanation of
the manner in which the term is used for the purposes of this plan.
In-Network
Services received from or coordinated by your Primary Care Physician.
Primary Care Physician
The doctor you have selected from the Provider Directory to manage your health care. Your Primary
Care Physician will render or coordinate most of your care.
Out-of-Network
Services received without a referral or from someone other than your Primary Care Physician or
authorized specialist
Referrals
A document, which authorizes you to receive care from a participating physician or other health care
provider. A referral is authorized by your Primary Care Physician and sent to you by the insurance
company.
Schedule of Allowances
The Schedule of Allowances is the schedule of amounts that in-network providers have agreed to
accept as full payment for their services.
Page 12
POS
10/01/02
Subject to the approval of NYS Insurance Department